CMS-1490S Health Insurance Common Claim Form (Spanish)

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C (CMS-1500 and CMS-1490S)

CMS-1490S_English

OMB: 0938-1197

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

Form Approved OMB
No. 0938-1197

PATIENT’S REQUEST FOR MEDICAL PAYMENT
IMPORTANT: PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE
SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR – Include a copy of the
itemized bill and any supporting documents. Make a copy of your claim submission for your records and allow at
least 60 days for Medicare to receive and process your request.
Reference the Medicare Administrative Contractor Address Table for the correct address to mail your claim form.
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.
Your reason for submitting this claim: (see the Instructions for additional information, check one box only)
The provider or supplier refused to file a claim for Medicare Covered Services
The provider or supplier is unable to file a claim for the Medicare Covered Services
The provider or supplier is not enrolled with Medicare
IF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY USERS SHOULD CALL 1-877-486-2048.
Type of Patient’s Request (see instructions for additional information, check one box only):
Influenza/Pneumococcal Vaccination, Part B (includes physician, laboratory, imaging services), Foreign
Travel (including Canada and Mexico) and/or Shipboard Services
Durable Medical Equipment, Prosthetics, Orthotics and Supplies

PLEASE TYPE OR PRINT INFORMATION

SECTION 1 - PATIENT INFORMATION
Patient’s Name as shown on Medicare Card (Last, First, Middle)

Patient’s Medicare Number exactly as it is shown on the Medicare card:

Date of Birth (mm/dd/yyyy)

Male

Female

Street address (or P.O. Box - include apartment number)

City

State

Zip code

Telephone number

Form CMS-1490S (version 01/18)

SECTION 2 - INFORMATION ABOUT SERVICES FURNISHED
FOR ALL CLAIMS including Influenza and Pneumococcal Vaccinations, 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) If known
IMPORTANT: If the itemized bill is from:
• A Clinical laboratory for ordered tests
• An independent diagnostic imaging center for ordered imaging procedures
• A supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for ordered DMEPOS
The ordering & referring providers legal name MUST be included on the itemized bill.
Please also include the ordering & referring providers National Provider Identifier (NPI) if known.
Was the condition related to:
Yes

Employment

Yes

Auto Accident

Yes

Treatment for chronic dialysis or kidney transplant

Yes

Other Accident

SECTION 3 - INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE
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 covered by any medical coverage other than Medicare.
Yes

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 (VA)?

Name of other Medical Insurance

Policy Number including Medicaid ID Number

Policyholder’s Name (Last, First, Middle)

Street Address (or P.O. Box) of other Medical Insurance

City

State

Zip code

Please attach a copy of your primary insurer’s Explanation of Benefits if Medicare is secondary.
Form CMS-1490S (version 01/18)

SECTION 4 - 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.
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.
Signature of Patient
Date Signed (mm/dd/yyyy)

If you cannot sign your name, mark an (X) on the signature line. Have a witness sign his/her name next to the “X” and complete the section
below.
If signing this form on behalf of a Medicare patient, on the ‘Signature of Patient’ line above, indicate the patient’s name followed by “By” and
sign your name. Provide your name, address, and relationship to the patient with a brief explanation why the patient cannot sign.
Name of Witness (Last, First, Middle)

Street Address

City

State

Zip code

Relationship to the Patient

Signature of Witness

Date Signed (mm/dd/yyyy)

Briefly explain why the Patient cannot sign:

Send the completed form and supporting documentation to your Medicare contractor. Reference the
Medicare Administrative Contractor Address table for the correct address to mail your claim form. 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.
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 0938-1197. The time required to complete this
information collection is estimated to average 15 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, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Baltimore, Maryland 21244-1850. DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this
address will significantly delay application processing.
Form CMS-1490S (version 01/18)

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, Medicare Administrative Contractor (MAC),
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.

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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 Medicare
number, would delay payment of the claim.

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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. If you are being treated for a work related injury be sure to check the
appropriate box in Section 2 titled ‘Condition Related to’.

Physicians and other suppliers, such as clinical laboratories, 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.

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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/physiciancompare
or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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.

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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.

NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon conviction
be subject to fine and imprisonment under Federal law. No Part B Medicare benefits may be paid unless this form is
received as required by existing law and regulations (20 CFR 422.510).

Form CMS-1490S (version 01/18)

INSTRUCTIONS
READ BEFORE SUBMITTING A CLAIM TO MEDICARE
(PLEASE RETURN ONLY THE FORM AND NOT THE INSTRUCTION)
Patient’s Request for Medical Payment for the Influenza/Pneumococcal Vaccinations, Part B Services, (includes
physician, laboratory, imaging services), Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Foreign
Travel (including Canada and Mexico) and Shipboard Services
Influenza and Pneumococcal Vaccination:
Medicare may pay for seasonal influenza and pneumococcal vaccinations. Annual Part B deductible and
coinsurance amounts do not apply. Medicare does not pay for the hepatitis B vaccines. All physicians, non-physician
practitioners, and suppliers who administer seasonal influenza vaccinations must take assignment on the claim for
the vaccine.

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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.

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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):
Medicare law prohibits payment for health care services furnished outside the United States (U.S.) except in certain
limited circumstances. 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.
Services furnished on a ship in a U.S. port or within 6 hours of when the ship arrived at or departed from a U.S. port
are furnished inside the U.S.

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There are three situations when Medicare may pay for certain types of health care services rendered in a foreign
hospital (a hospital outside the U.S.):
1. You’re in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest U.S.
hospital that can treat your illness or injury.

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2. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and
another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S.
hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable
delay” on a case-by-case basis.

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3. 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 it’s an emergency.

In these situations, Medicare will pay for the Medicare-covered services you get in the foreign hospital and the
physician and ambulance services furnished in connection with that foreign inpatient hospital stay.

Shipboard Services:
Medicare may pay for medically necessary services furnished on a ship in a U.S. port or within 6 hours of when the
ship arrived at or departed from a U.S. port only if all of the following requirements are met:

• You have Part B benefits
• The physician is legally authorized to practice in the U.S.
If the ship is more than 6 hours away from a U.S. port, Medicare can pay for medically necessary services only if all
of the following requirements are met:
1. You have a medical emergency within 6 hours of departing or arriving at a U.S. port that requires
inpatient hospital services.
2. The nearest or most accessible hospital that can treat you is a foreign hospital rather than a U.S. hospital.
3. The services are to treat the emergency illness or injury.
4. You have Part B benefits.
5. The physician is legally authorized to practice where he or she furnished the services
For shipboard services please include a copy of the ship’s itinerary.
Form CMS-1490S (version 01/18)

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.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also
have the right to file a complaint if you believe you’ve been discriminated against. Visit https://www.medicare.gov/
about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information.
FOLLOW THESE INSTRUCTIONS CAREFULLY:
A. Your Reason for submitting this Claim
Check the box that applies to this claim
B. Type of Patient’s Request
Check only one box that applies to this claim

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Section 1 – PATIENT INFORMATION
• Print your name as shown on your Medicare card (Last Name, First Name, Middle Name).
• Print your Medicare Number exactly as it is shown on the Medicare card.
• Print your date of birth (mm/dd/yyyy)

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• Check the appropriate box for the patient’s sex.

• Patient’s Condition related to: Check the appropriate boxes

Section 2 – INFORMATION ABOUT SERVICES FURNISHED
• Describe the illness or injury for which you received treatment

• Furnish your mailing address and include your telephone number

NOTE: You must attach an itemized bill in order for Medicare to process this claim.

Attach all supporting documentation to the form including an itemized bill with the following information:
• Charge for each service

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• Date of service
• Place of service

• The doctor’s or supplier’s name and address

• Description of illness or injury

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• Description of each surgical or medical
service or supply furnished

• The provider or supplier’s National Provider Identifier
(NPI) If known
• The ordering & referring Providers Full Legal Name
and address if required as indicated in Section 2

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• It is helpful if the diagnosis is shown on the physician’s itemized bill. If not, be sure you have completed Section
2 of this form.
• Many times a bill will show the names of several doctors or suppliers. It is very important the provider who
treated you be identified. Simply circle his/her name on the bill.

• Mark out any services on the itemized bill(s) you are attaching for which you have already filed a Medicare
claim.

• Attach a copy of your primary insurer’s Explanation of Benefits notice if you are requesting Medicare Secondary
payment.

• Shipboard services please include a copy of the ship’s itinerary.
Section 3 – INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE
• Complete this Section if you are age 65 or older and
• Name of other Medical Insurance
enrolled in a health insurance plan where you or your • Policy Number including Medicaid ID Number
spouse are currently working and if you have any
• Policyholder’s Name
medical coverage other than Medicare.
• Street Address of other Medical Insurance
• Check all boxes that apply
Section 4 – SIGNATURE
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.
Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY,
IMAGING SERVICES)
Mail your claim form, itemized bill and supporting documents to:

Alabama

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

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

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If you received a
service in:

(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:

California Northern
(For Part B)

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

California Southern
(For Part B)

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

Colorado

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

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

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Arizona

Novitas Solutions, Inc.
Attention: 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: 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

Novitas Solutions
P.O. Box 3396
Mechanicsburg, PA 17055-1841

Form CMS-1490S (version 01/18)

Florida

First Coast Service Options, Inc.
P.O. Box 2009
Mechanicsburg, PA 17055-0709

Georgia

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

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

Illinois

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

Indiana

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

Iowa

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

Kansas

Wisconsin Physicians Service
P.O. Box 7238
Madison, WI 53707-7238

Kentucky

CGS Administrators, LLC
P.O. Box 20019
Nashville, TN 37202

Louisiana

Novitas Solutions, Inc.
P.O. Box 3097
Mechanicsburg, PA 17055-1815

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If you received a
service in:

Maine

Form CMS-1490S (version 01/18)

(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: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY,
IMAGING SERVICES)
If you received a
service in:

Mail your claim form, itemized bill and supporting documents to:

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:

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

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

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

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Massachusetts

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Novitas Solutions, Inc.
Attention: 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:

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Novitas Solutions, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
Wisconsin Physicians Service
P.O. Box 14260
Madison, WI 53708-0260

Montana

Noridian Healthcare Solutions, LLC
P.O. Box 6735
Fargo, ND 58108-6735

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Missouri

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Nevada

Wisconsin Physicians Service
P.O. Box 8667
Madison, WI 53708-8667

Nebraska

New Hampshire

Form CMS-1490S (version 01/18)

Noridian Healthcare Solutions, LLC
P.O. Box 6776
Fargo, ND 58108-6776
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY,
IMAGING SERVICES)
If you received a
service in:

Mail your claim form, itemized bill and supporting documents to:

New Jersey

Novitas Solutions
P.O. Box 3030
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
P.O. Box 3107
Mechanicsburg, PA 17055-1834

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New Mexico

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

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

Northern Mariana
Islands

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

Ohio

CGS Administrators, LLC
P.O. Box 20019
Nashville, TN 37202

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

Oklahoma

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New York

Novitas Solutions, Inc.
Attention: 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 Solution
P.O. Box 3107
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: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Oregon

Form CMS-1490S (version 01/18)

Noridian Healthcare Solutions
P.O. Box 6702
Fargo, ND 58108-6702
10

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN,
LABORATORY, IMAGING SERVICES)
If you received a
service in:

Mail your claim form, itemized bill and supporting documents to:

Pennsylvania

Novitas Solutions
P.O. Box 3418
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: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Puerto Rico

First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704

Rhode Island

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

South Carolina

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

South Dakota

Noridian Healthcare Solutions, LLC
P.O. Box 6707
Fargo, ND 58108-6707

Tennessee

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

Texas

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Novitas Solutions
P.O. Box 3108
Mechanicsburg, PA 17055-1834

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(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: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Utah

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 (Arlington
and Fairfax
Counties, including
city of Alexandria)

Novitas Solutions
P.O. Box 3396
Mechanicsburg, PA 17055-1841

Virginia (The rest
of the state.)

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

Form CMS-1490S (version 01/18)

Virgin Islands

First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704

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

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If you received a
service in:

FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS) ONLY
If you live in:

Mail your form and supporting documentation to:

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Connecticut, Delaware, District of Columbia, Maine,
Noridian JA
Maryland, Massachusetts, New Hampshire, New Jersey, P.O. Box 6780
New York, Pennsylvania, Rhode Island, Vermont
Fargo, ND 58108-6780
CGS Administrators, LLC
P.O. Box 20013
Nashville, TN 37202-0013

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

CGS Administrators, LLC
P.O. Box 20010
Nashville, TN 37202-0010

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

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

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

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
Mail your claim form, itemized bill and supporting documents to:

Alabama

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

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

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LA
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If you live in:

U
R

(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:

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

California Southern
(For Part B)

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

Colorado

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

H
IT

California Northern
(For Part B)

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

SE
N

TH
IS

PA
G

Arizona

Novitas Solutions, Inc.
Attention: 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:

Connecticut

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

Novitas Solutions
P.O. Box 3396
Mechanicsburg, PA 17055-1841

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live in:

Mail your claim form, itemized bill and supporting documents to:

Florida

First Coast Service Options, Inc.
P.O. Box 2009
Mechanicsburg, PA 17055-0709

Georgia

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

Guam

Noridian Healthcare Solutions, LLC

Hawaii

Noridian Healthcare Solutions, LLC

Idaho

Noridian Healthcare Solutions, LLC

Illinois

National Government Services, Inc.

Indiana

Wisconsin Physicians Service

Iowa

Wisconsin Physicians Service

Kansas

Wisconsin Physicians Service

Kentucky

CGS Administrators, LLC
P.O. Box 20019
Nashville, TN 37202

Louisiana

Novitas Solutions, Inc.
P.O. Box 3097
Mechanicsburg, PA 17055-1815

C
LA
IM

P.O. Box 6777
Fargo, ND 58108-6777

U
R

P.O. Box 6777
Fargo, ND 58108-6777

P.O. Box 6701
Fargo, ND 58108-6701

IT
W

TH
IS

PA
G

P.O. Box 8940
Madison, WI 53708-8940
P.O. Box 8550
Madison, WI 53708-8550

P.O. Box 6475
Indianapolis, IN 46206-6475

SE
N

P.O. Box 7238
Madison, WI 53707-7238

(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:

Maine

Form CMS-1490S (version 01/18)

Novitas Solutions, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live in:

Mail your claim form, itemized bill and supporting documents to:

Maryland

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

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

U
R

Massachusetts

C
LA
IM

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

PA
G

(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:

TH
IS

Novitas Solutions, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
Wisconsin Physicians Service
P.O. Box 14260
Madison, WI 53708-0260

Montana

Noridian Healthcare Solutions, LLC
P.O. Box 6735
Fargo, ND 58108-6735

Nebraska

Wisconsin Physicians Service
P.O. Box 8667
Madison, WI 53708-8667

Nevada

SE
N

Missouri

New Hampshire

Form CMS-1490S (version 01/18)

Noridian Healthcare Solutions, LLC
P.O. Box 6776
Fargo, ND 58108-6776
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live in:

Mail your claim form, itemized bill and supporting documents to:

New Jersey

New Mexico

C
LA
IM

Novitas Solutions, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
Novitas Solutions
P.O. Box 3107
Mechanicsburg, PA 17055-1834

U
R

(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:

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

Northern Mariana
Islands

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

Ohio

CGS Administrators, LLC
P.O. Box 20019
Nashville, TN 37202

IT
W

North Carolina

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

Oklahoma

SE
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TH
IS

PA
G

New York

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

Oregon

Form CMS-1490S (version 01/18)

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

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live in:

Mail your claim form, itemized bill and supporting documents to:

Pennsylvania

Puerto Rico

First Coast Service Options, Inc.
P. O. Box 2004
Mechanicsburg, PA 17055-0704

Rhode Island

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

South Carolina

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

South Dakota

Noridian Healthcare Solutions, LLC
P.O. Box 6707
Fargo, ND 58108-6707

Tennessee

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

Texas

Novitas Solutions
P.O. Box 3108
Mechanicsburg, PA 17055-1834

D
N
E

S
I
H

E
G
PA

M
I
A

R
U
O

(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:

Utah

Novitas Solutions, Inc.
Attention: 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 (Arlington
and Fairfax
Counties, including
city of Alexandria)

Novitas Solutions
P.O. Box 3396
Mechanicsburg, PA 17055-1841

Virginia (The rest
of the state.)

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

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
Mail your claim form, itemized bill and supporting documents to:

Virgin Islands

First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704

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

N
O

N
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G
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W
IT
H

U
R

C
LA
I

If you live in:

Form CMS-1490S (version 01/18)

File Type	application/pdf
File Title	1490S-Patient's Request for Medical Payment
Subject	1490S-Patient's Request for Medical Payment, form, Centers for Medicare & Medicaid Services
Author	Centers for Medicare & Medicaid Services
File Modified	2022-06-13
File Created	2018-01-18