Patient’s Request for Medical Payment Form CMS-1490S

20 - Patient’s Request for Medical Payment Form CMS-1490S (Rev.: 4388; Issued: 09-06-19; Effective: 10-07-19; Implementation: 10-07-19) The CMS implemented a new version of the Form CMS-1490S effective January 1, 2019. The revised form is version 01/18, OMB control number 0938-1197. The revised form will replace the previous version of the form 01/05, OMB control number 0938- 0999. The term, “Form CMS-1490S” refers to the form generically, independent of a given version. Medicare will conduct a dual-use period (January 1, 2019 through March 31, 2019) during which Beneficiaries (or their representatives) can send Medicare claims on either the old or the revised form. When the dual-use period is over, Medicare will accept beneficiary paper claims on only the revised Form CMS-1490S, version 01/18. This form is used only by beneficiaries (or their representatives) who complete and file their own claims. It contains the patient’s comparable items of data that are on the Form CMS-1500. When the Form CMS-1490S is used, an itemized bill must be submitted with the claim. Some enrollees may want to keep the original itemized physician and supplier bills for income tax or complementary insurance purposes. Photocopies of itemized bills are acceptable for Medicare deductible and payment purposes if there is no evidence of alteration. Social Security offices use the Form CMS-1490S when assisting beneficiaries in filing Part B Medicare claims. Although §1848(g)(4) of the Act requires physicians and suppliers to submit Part B Medicare claims for services furnished on or after September 1, 1990, contractors continue to accept, process, and pay for covered services submitted by beneficiaries on a Form CMS-1490S if there is no clear indication that the service provider intends to file a claim. An itemized bill for services on or after September 1, 1990, which clearly indicates the physician or supplier intends to file a Part B claim for the patient, may be returned to the beneficiary. For Medicare covered services received on or after September 1, 1990, the Form CMS- 1490S is used by beneficiaries to submit Part B claims only if the service provider refuses to do so or if one of the following situations applies: • DME purchases from private sources; • Cases in which a physician/supplier does not possess information essential for filing an MSP claim. Assume this is the case if the beneficiary files an MSP claim and encloses the primary insurer's payment determination notice and there is no indication that the service provider was asked to file but refused to do so; • Services paid under the indirect payment procedure; • Foreign claims; • Services furnished by sanctioned physicians and suppliers which are approved for payment to the beneficiary per the Program Integrity Manual (PIM); and • Other unusual or unique situations that are evaluated on a case-by-case basis. If the contractor approves 11 or more Form CMS-1490S claims in a calendar month for services performed on or after September 1, 1990, by the same physician or supplier, monitor the provider's claims submissions and take appropriate action. The contractor continues to stock Form CMS-1490S and, upon request, furnish beneficiaries with these forms. (Beneficiaries need these forms to file claims for services that physicians/suppliers are not required to submit (e.g., services prior to September 1, 1990), or refuse to submit to Part B on their behalf.)