CMS-1490s Patient Request for Medical Payment

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C

CMS-1490S-English-090116

CMS-1500 (02-12)/CMS-1490S

OMB: 0938-1197

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1197 can be found here:

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO XXXX-XXXX

Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or for items paid for under
the DMEPOS Competitive Bidding program.

Patient’s Request for Medical Payment
IMPORTANT: Attach itemized bills from your doctor(s) or supplier(s) to this form.
MEDICAL INSURANCE BENEFITS UNDER SOCIAL SECURITY ACT
SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR – SEE PAGE 9 FOR LIST OF
ADDRESSES.
IF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Type of Patient Request (see instructions on Page 8 for
additional information, check one box only):
Influenza/Pneumococcal Vaccination
Part B (includes physician, laboratory, imaging services)

Durable Medical Equipment, Prosthetics,
Orthotics and Supplies
Foreign Travel (including Canada or Mexico)
Shipboard Services

PLEASE TYPE OR PRINT INFORMATION

Section 1 - Information about You
First Name:
Male

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Print your name as shown on your Medicare Card

Last Name:

Female

Date of Birth ______/_____/_______

Middle Name:

Print your Health Insurance Claim Number exactly as it is shown on your Medicare Card

State

City

Your Mailing Address:
Street or P.O. Box – include apartment number:

ZipCode

Check here if this is a new address
Day time phone number including Area
Code
(_ _ _) _ _ _ - _ _ _ _

If you DO NOT want payment information
from this claim released to your other
insurer, check the following box

Section 2 - Information about Service(s) Furnished
FOR ALL CLAIMS INCLUDING Influenza and Pneumococcal Vaccinations
Enter the diagnosis and describe the illness or injury for which you received treatment.
Attach all supporting documentation to the form including an itemized bill with the following information:
•
Date of service,
•
Place of service,
•
Description of illness or injury,
•
Description of each surgical or medical service or supply furnished,
•
Charge for each service,
•
The doctor’s or supplier’s name and address,
•
The provider or supplier’s National Provider Identifier (NPI)

FORM CMS-1490S (SC) (XX/XX) EF 09/2019
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Do not mail your claim form to
this address. Mailing a claim form to this address will result in the form and its attachments being returned to you.

Was the Condition related to:
Your employment?

Yes

Treatment for chronic dialysis or kidney transplant?

Yes

Accident

Yes

If the answer is yes,

Auto

Other

ADDITIONAL INFORMATION FOR VACCINATION
Attach receipt from the physician/ provider that gave you the vaccination. The receipt should include:
Provider’s name
Provider’s Address
Date of Service
Charge for the Service

Section 3 - Information About Health Insurance Other than Medicare
Complete this section if you are:

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Age 65 or older and enrolled in a health insurance plan where you or your spouse are currently working and covered by
any other medical insurance other than Medicare
Are you employed and covered under an employee health plan

Yes

Is your spouse employed and are you covered under your spouse’s employee health plan

Yes

Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP, employment related
insurance, Medicaid, or the Veterans Administration
Name of other medical coverage:
Address of other medical coverage:

State

ZipCode

City

Policy number including Medicaid or Medical Assistance
number:

Street or P.O. Box

Yes

Policy Holder’s name: (Last, First, Middle)

Please add a copy of your primary insurer’s Explanation
of Benefits if Medicare is secondary.

Section 4 - Information about Your Physician or Eligible Practitioner
Name of physician or eligible practitioner (e.g.; Nurse Practitioner, Physician Assistant) who treated you:
First Name:

Last Name:

Middle Name:

National Provider Identifier (NPI), if known
Location of Service:
Street
State

City
ZipCode

Date of Service: Month

Day

Year

Did your physician, or other individual practitioner, refer you to a clinical laboratory, an independent diagnostic testing
facility, a portable x-ray supplier, or any other supplier for additional test or services:
Yes If yes, complete section 5 and section 6

If no, skip section 5 and complete section 6

Section 5 - Information about Your Supplier or Physician’s Supplier

If you received medical services from a clinical laboratory, independent diagnostic testing facility, or a supplier complete the
information below.
Name of Supplier:
National Provider Identifier (NPI), if known:
Location of Service:
Street of P.O. Box
City

State

Date of Service: Month

Day

ZipCode

Year

Section 6 -Signature
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements
or forms, and it is true and correct to the best of my knowledge. Anyone who misrepresents or falsifies essential information
requested by this form may upon conviction be subject to fine and imprisonment under Federal law.

Signature of Patient
Date signed --------/--------/---------

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I authorize any holder of medical or other information about me to release it to the Centers for Medicare & Medicaid Services
or its designated contractor or the Social Security Administration for this Medicare claim. I permit a copy of this authorization
to be used in place of the original, and request payment of medical insurance benefits to me.

All signatures must be original and signed in ink (blue ink preferred). Stamped, faxed or copied signatures will not
be accepted.
If you are unable to sign, check the box:

Then have a witness sign and include his/her address below.

First Name

Middle Name

Name of witness: Last name

If you are completing this form for another Medicare patient, you should write your name, sign and include your address. Also
you should show your relationship to the patient and briefly explain why the patient cannot sign.

Signature of Witness
Date signed:

--------/--------/---------

Relationship with the patient:

Reason why the patient cannot sign:

Send the completed form and supporting documentation to your Medicare contractor. For address of your Medicare
Contractor, please see list starting on Page 11. If you still do not know the address of your Medicare contractor, call
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

DO NOT SEND THE FOLLOWING PAGES WITH THE FORM
Patient’s Request for Medical Payment for the Flu Shot, Part B Services, including Durable
Medical Equipment, Prosthetics, Orthotics and Suppliers (DMEPOS), Foreign Travel (including
Canada and Mexico) and Shipboard Services
Physicians and other suppliers, such as clinical laboratories and imaging service suppliers,
and durable medical equipment suppliers, are required by law to submit a claim for
Medicare covered services furnished to you, the Medicare beneficiary, within one year of
the date of service.
To reduce your out-of-pocket expenses, Medicare beneficiaries should always obtain medical
care from physicians and other suppliers who are enrolled in the Medicare program. If you
submit a claim for covered services furnished by a physician or other supplier who is not
enrolled with the Medicare program, your claim may be denied.

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For a list of participating Medicare enrolled physicians in your area, please go to
www.medicare.gov and select physician compare or call 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048.
To file a claim with Medicare, please complete all sections of this form, provide an itemized
bill from your physician or supplier, attach any supporting medical information you feel is
necessary, and explain in detail your reason for submitting the claim. For example, write a
purpose statement notifying the Medicare contractor of your situation. Common situations
include:
• your provider or supplier refused or is unable to file a claim for a Medicare-covered
service
• your provider or supplier is not enrolled with Medicare

If a physician or supplier furnishes Medicare covered services to you and refuses to submit a
claim on your behalf for those services, please call 1-800-MEDICARE (1-800-633-4227) in order
to file a complaint with the Medicare contractor. TTY users should call 1-877-486-2048.
When you submit your own claim to Medicare, complete the entire form. If the claim form has
incomplete or invalid information, the Medicare contractor will return the claim along with a
letter to you clearly stating what information is missing or invalid.
If the patient is deceased, please contact your Social Security office for instructions on how to
file a claim.
See Page 6 for Collection and Use of Medicare Information
See Pages 7-8 for instructions about how to fill out the form and the supporting
documentation needed
See pages 9-14 for information on where to mail this form.
FORM CMS-1490S (SC) (XX/XX) EF 09/2019
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Do not mail your claim form to
this address. Mailing a claim form to this address will result in the form and its attachments being returned to you.

Read Before Submitting a Claim to Medicare
(Please return only the form and NOT the instruction)
General Instructions
•

If you are submitting a claim for services from a doctor or eligible practitioner, then complete sections 1 – 4, sign and date
the form.

•

If you are submitting a claim for services from a clinical laboratory, independent diagnostic testing facility, or supplier of
medical equipment, then complete all sections, sign and date the form.

•

Send the completed claim form, your itemized bill, and any supporting documents to the appropriate Medicare contractor
and explain in detail your reason for submitting the claim. For example, include a statement that notifies the Medicare
contractor that your provider or supplier refused or is unable to file a claim for a Medicare-covered service and/or is not
enrolled with Medicare.

•

You should make copies of your claim submission for your records. Please allow at least 60 days for Medicare to receive
and process your request. If you have any other questions, please feel free to call us at 1-800-MEDICARE (1-800-633-4227).

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Seasonal Influenza and Pneumococcal Vaccination:
Medicare may pay for seasonal influenza and pneumococcal vaccinations. Medicare does not pay for the hepatitis B vaccines
Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who
administer seasonal influenza vaccination must take assignment on the claim for the vaccine.
Part B Services:

In most situations, your physician, other practitioner or supplier will submit your claim to Medicare, if they do not, you can
submit a claim.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies:

In most situations, your supplier of DMEPOS will submit your claim to Medicare, if they do not, you can submit a claim for an
item or services furnished by this supplier.

Foreign Travel (including Canada and Mexico):

In most situations, Medicare will not pay for health care outside the United States (U.S.) and its territories. The term “outside
the U.S.” means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands,
Guam, American Samoa, and the Northern Mariana Islands.
Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign hospital (a hospital outside the
U.S.) in the following situations:
•

If an emergency arose within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your
medical condition.

•

If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your
medical condition, regardless of whether an emergency exists.

Shipboard Services:
Medicare may pay for medically necessary shipboard services if the services were provided while the ship was within United
States (U.S.) waters. If you had medical services aboard a ship and the doctor’s office is not in the U.S., then you can submit
a claim to Medicare. If you had medical services aboard a ship and the doctor’s office is located in the U.S., the doctor will
submit the claim to Medicare.

COLLECTION AND USE OF MEDICARE INFORMATION
We are authorized by the Centers for Medicare & Medicaid Services to ask you for information needed in the administration
of the Medicare program. Authority to collect information is in section 205(a), 1872 and 1875 of the Social Security Act, as
amended.
The information we obtain to complete your Medicare claim is used to identify you and to determine your eligibility. It is also
used to decide if the services and supplies you received are covered by Medicare and to insure that proper payment is made.
The information may also be given to other providers of services, carriers, intermediaries, medical review boards, and other
organizations as necessary to administer the Medicare program. For example, it may be necessary to disclose information to a
hospital or doctor about the Medicare benefits you have used.
With one exception, which is discussed below, there are no penalties under Social Security law for refusing to supply
information. However, failure to furnish information regarding the medical services rendered or the amount charged would
prevent payment of the claim. Failure to furnish any other information, such as name or claim number, would delay payment
of the claim.
It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether worker’s
compensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminal penalties for
withholding this information.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If
you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Do not mail your claim form to this address. Mailing a claim form to this address will result in the form and its attachments
being returned to you.

HOW TO FILL OUT THIS MEDICARE FORM
Medicare may pay you directly when you complete this form and attach an itemized bill from your doctor or supplier.
Mail your completed claim form to the Medicare contractor responsible for processing your claim. If you need additional
assistance, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

FOLLOW THESE INSTRUCTIONS CAREFULLY:

Check one of the following on top of the form: Seasonal Influenza and Pneumococcal Vaccination or Part B Services (includes
physician, laboratory, imaging services) or Durable Medical Equipment, Prosthetics, Orthotics and Supplies or Foreign Travel
(including Canada or Mexico) or Shipboard Services.

Section 1 – Information about you
Print your name shown on your Medicare Card (Last Name, First Name, Middle Name).
Check the appropriate box for the patient’s sex.
Print your Health Insurance Claim Number including the letter at the end
Furnish your mailing address and include your telephone number

Section 2- Information about services furnished
Enter the diagnosis and describe the illness or injury for which you received treatment.
Check the appropriate boxes

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For Seasonal Influenza/Pneumococcal vaccination, attach receipt from the physician/provider that gave you the vaccination.
The receipt should include:
Provider’s Name, Provider’s Address, Date of Service and Charge for the Service

Section 3 – Information about other Health Care Payers

Complete this Section if you are age 65 or older and enrolled in a health insurance plan where you or your spouse are
currently working and if you have any medical coverage other than Medicare.
Be sure to provide the name of the other Medical Coverage

Policy number of the private insurance or MEDIGAP or Medicaid/Medical Assistance/VA or any other Medical Coverage you
may have.

Address of the other Medical Coverage you may have

If the policy is not in your name, include the Policy Holder’s name

Section 4 - Information about your Physician or Eligible Practitioner (e.g.; Nurse Practitioner,
Physician Assistant, Dentist etc)
Enter the name of your physician or eligible practitioner
National Provider Identifier of your physician or the eligible practitioner, if known
Location of Service
Date of Service
Whether you were referred to a laboratory, independent diagnostic testing facility or a supplier

Section 5-Information about Durable Medical Equipment, Prosthetics, Orthotics, Supplies and
Portable X- Ray Supplier
Complete this section if you have received medical services from a clinical laboratory, independent diagnostic testing facility,
portable x-ray supplier.
Include the name of the service provider
National Provider Identifier, if known
Location of Service and Date of Service

Section 6- Signature and Date
Sign your name and date the form
If the Medicare beneficiary is not able to sign his/her name, follow the instructions on the form.

Attach the itemized bill and other supporting documentation
You must attach an itemized bill in order for Medicare to process this claim.

Each itemized bill MUST show all of the following information:
Date of each service
Place of each service
Doctor’s Office
Independent Laboratory
Patient’s Home
Inpatient Hospital

Outpatient Hospital Nursing Home

Description of each surgical or medical service or supply furnished
Charge for each service
Doctor’s or supplier’s name and address
Many times a bill will show the names of several doctors or suppliers. It is very important the one who treated you be
identified. Simply circle his/her name on the bill.

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It is helpful if the diagnosis is also shown on the physician’s bill. If not, be sure you have completed section 2 of this form.
Mark out any services on the bill(s) you are attaching for which you have already filed a Medicare claim.
If the patient is deceased, please contact your Social Security office for instructions on how to file a claim.
Attach an Explanation of Medicare Benefits notice from the other insurer if you are also requesting Medicare payment.

Send the completed claim form and supporting documentation to the appropriate
Medicare contractor for your claim (see list on page 11). If you need help, call
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

FOR SEASONAL INFLUENZA AND PNEUMOCOCCAL VACCINATION, PART B SERVICES,
FOREIGN TRAVEL AND SHIPBOARD SERVICES.
If you received a service in:

Return your form to:

Alabama

Cahaba Medicare Part B
P.O. Box 6169 Indianapolis, IN 46206

Alaska

Noridian Healthcare Solutions, LLC
P.O. Box 6703
Fargo, ND 58108-6703

American Samoa

Noridian Healthcare Solutions, LLC
P.O. Box 6777
Fargo, ND 58108-6777

Arkansas

Novitas Solutions, Inc.
P.O. Box 3098
Mechanicsburg, PA 17055-1816
(Address to send Medicare 1490 claims via Priority mail or through a commercial courier (UPS, FedEx) for which a PO Box cannot be used, please
use the following street address:

Arizona

Noridian Healthcare Solutions , LLC
P.O. Box 6704
Fargo, ND 58108-6704

California Northern (For Part B)

California Southern (For Part B)

Noridian Healthcare Solutions
P.O. Box 6774
Fargo, ND 58108-6774

Noridian Healthcare Solutions, LLC
P.O. Box 6775
Fargo, ND 58108-6775

Novitas Solutions
P.O. Box 3107
Mechanicsburg, PA 17055-1823

Colorado

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Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )

(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:
Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Connecticut

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

Delaware

Novitas Solutions
P.O. Box 3397
Mechanicsburg, PA 17055-1842

District of Columbia (Washington DC)

Novitas Solutions, Inc.
P.O. Box 3396
Mechanicsburg, PA 17055-1841
(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:
Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050
First Coast Service Options, Inc.
P.O. Box 2525
Jacksonville, FL 32231-0019

Georgia

Cahaba Medicare Part B
P.O. Box 6169 Indianapolis, IN 46206

Guam

Noridian Healthcare Solutions, LLC
P.O. Box 6777
Fargo, ND 58108-6777

Hawaii

Noridian Healthcare Solutions, LLC
P.O. Box 6777
Fargo, ND 58108-6777

Idaho

Noridian Healthcare Solutions, LLC
P.O. Box 6701
Fargo, ND 58108-6701

Iowa

Kansas

Kentucky

Wisconsin Physicians Service
P.O. Box 8940
Madison, WI 53708-8940
Wisconsin Physicians Service
P.O. Box 8550
Madison, WI 53708-8550

Indiana

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Illinois

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Florida

Louisiana

Wisconsin Physicians Service
P.O. Box 7238
Madison, WI 53707-7238
CGS Administrators, LLC
P.O. Box 20019 Nashville, TN 37202
Novitas Solutions, Inc.
P.O. Box 3097
Mechanicsburg, PA 17055-1815
(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:
Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Maine

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

Maryland

Novitas Solutions, Inc.
P.O. Box 3398
Mechanicsburg, PA 17055-1843
(Address to send Medicare 1490 claims via Priority mail or through a commercial courier (UPS, FedEx) for which a PO Box cannot be used, please
use the following street address:
Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )
National Government Services, Inc.
P.O. Box 6178 Indianapolis, IN 46206-6178

Michigan

Wisconsin Physicians Service
P.O. Box 8987
Madison, WI 53708-8987

Minnesota

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Mississippi

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Massachusetts

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834

(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:

Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )

Nebraska

Montana

Wisconsin Physicians Service
P.O. Box 14260 Madison, WI 53708-0260

Missouri

Noridian Healthcare Solutions, LLC
P.O. Box 6735
Fargo, ND 58108-6735
Wisconsin Physicians Service
P.O. Box 8667
Madison, WI 53708-8667

Nevada

Noridian Healthcare Solutions, LLC
P.O. Box 6776
Fargo, ND 58108-6776

New Hampshire

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

New Jersey

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834
(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:
Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )

New Mexico

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834

(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:
Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

North Carolina

Palmetto GBA, LLC Mail Code: AG-600
P.O. Box 100190 Columbia, SC 29202-3190

North Dakota

Noridian Healthcare Solutions, LLC
P.O. Box 6706
Fargo, ND 58108-6706

Oklahoma

Noridian Healthcare Solutions
P.O. Box 6777
Fargo, ND 58108-6777

Northern Mariana Islands

Ohio

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New York

CGS Administrators, LLC
P.O. Box 20019 Nashville, TN 37202
Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834
(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used,
please use the following street address:

Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )
Oregon

Noridian Healthcare Solutions
P.O. Box 6702
Fargo, ND 58108-6702

Pennsylvania

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834

Rhode Island

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

South Carolina

Palmetto GBA
Mail Code: AG-600
P.O. Box 100190 Columbia, SC 29202-3190

South Dakota

Tennessee

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Puerto Rico

Noridian Healthcare Solutions, LLC
P.O. Box 6707
Fargo, ND 58108-6707
Cahaba Medicare Part B

P.O. Box 6169 Indianapolis, IN

Texas

Novitas Solutions
P.O. Box 3129

Mechanicsburg, PA 17055-1834

Utah

(Address to send Medicare 1490 claims via Priority mail or through a commercial courier (UPS, FedEx) for which a PO Box cannot be used, please
use the following street address:

Novitas Solutions, Inc. Attention: JL Claims Department
2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 )
Noridian Healthcare Solutions
P.O. Box 6725 Fargo, ND 58108-6725

Vermont

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

Virginia

Palmetto GBA
Mail Code: AG-600
P.O. Box 100190 Columbia, SC 29202-3190

Virgin Islands

First Coast Service Options, Inc.
P. O. Box 45098
Jacksonville, Florida 32232-5098

Washington

Noridian Healthcare Solutions
P.O. Box 6700
Fargo, ND 58108-6700

West Virginia

Palmetto GBA, LLC Mail Code: AG-600
P.O. Box 100190 Columbia, SC 29202-3190

Wisconsin

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Wyoming

Noridian Healthcare Solutions
P.O. Box 6708
Fargo, ND 58108-6708

FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS)
ONLY
If you live in:
Return your form and Supporting Documentation to:
Noridian JA DME
P.O. Box 6727
Fargo, ND 58108-6727

Illinois, Indiana, Kentucky, Michigan,
Minnesota, Ohio, Wisconsin
Indianapolis, IN 46207-7027

CGS Administrators, LLC
P.O. Box 20010
Nashville, TN 37202-001

Alabama, Arkansas, Colorado, Florida,
Georgia, Louisiana, Mississippi, New
Mexico, North Carolina, Oklahoma,
Puerto Rico, South Carolina,
Tennessee, Texas, U.S. Virgin Islands,
Virginia, West Virginia

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Connecticut, Delaware, District of
Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New Jersey,
New York, Pennsylvania,
Rhode Island, Vermont

Alaska, American Samoa, Arizona,
California, Guam, Hawaii, Idaho, Iowa,
Kansas, Missouri, Montana, Nebraska,
Nevada, North Dakota, Northern
Mariana Islands, Oregon, South
Dakota, Utah, Washington, Wyoming

Noridian JD DME
P.O. Box 6727
Fargo, ND 58108-6727

File Type	application/pdf
File Title	CMS-1490S-Draft-09012016
Author	CMS
File Modified	2016-09-01
File Created	2016-09-01