HOW TO FILL OUT THE MEDICARE CMS-1490S FORM
Medicare will pay you directly when you complete this form and attach an itemized bill from the company where you purchased the equipment.
FOLLOW THESE INSTRUCTIONS CAREFULLY:
Block 1. Print your name shown on your Medicare Card (Last Name, First Name, Middle Name).
Block 2. Print your Medicare Number including the letter at the end exactly as it is shown on your Medicare card.
Check the appropriate box for the patient's sex.
Block 3. Furnish your mailing address and include your telephone number in Block 3b.
Block 4. Describe the condition/medical reason for which you purchased the equipment. Check the appropriate box in Blocks 4b and 4c.
Block 5a. Complete this Block if you are age 65 or older and enrolled in a health insurance plan where you are currently working.
Block 5b. Complete this Block if you are age 65 or older and enrolled in a health insurance plan where your spouse is currently working.
Block 5c. Complete this Block if you have any medical coverage other than Medicare. Be sure to provide the Policy or Medical Assistance Number. You may check the box provided if you do not wish payment information from this claim released to your other insurer.
Block 6. Be sure to sign your name. If you cannot write your name, make an (X) mark. Then have a witness sign his or her name and address in Block 6 too.
If you are completing this form for another Medicare patient you should write (By) and sign your name and address in Block 6. You also should show your relationship to the patient and briefly explain why the patient cannot sign.
Block 6b. Print the date you completed this form.
Include an itemized bill that shows all of the following information:
Each itemized bill MUST show all of the following information:
- Date of purchase for each item
- Place of purchase for each item
- Description of each item furnished
- Charge for EACH item
- Make and manufacturer of the item purchased
- HCPCS code (if available) Seat Lift Chair HCPCS code is E0627
WHERE TO SEND THE CLAIM (INCLUDE A COPY OF THE COMPLETED CMN AND THE ITEMIZED BILL)
If you live in: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, VermontReturn your form to:
P.O. Box 9165
Hingham, MA 02043-9165
If you live in: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, WisconsinReturn your form to:
National Government Services, Inc.
Medicare DMEPOS Claims
P.O. Box 7027
Indianapolis, IN 46207-7027
If you live in: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, West VirginiaReturn your form to:
CIGNA Government Services
P.O. Box 20010
Nashville, TN 37202-0010
If you live in: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, WyomingReturn your form to:
Noridian Administrative Services
P.O. Box 6727
Fargo, ND 58108-6727
Position on a Patient's Right to Purchase Durable Medical Equipment (DME) from a Non-Medicare Company and be Reimbursed by Medicare provided Medicare Coverage Criteria and Guidelines are met
Updated: July 1, 2013
This document provides information and supporting documentation on the ability of a Medicare beneficiary to purchase Durable Medical Equipment (i.e. Seat Lift Chair) from a non- Medicare enrolled business and submit a claim to Medicare for reimbursement provided Medicare coverage criteria and guidelines have been met.
Providers of Durable Medical Equipment (DME) who are enrolled as a Medicare provider must, by law 1, submit a claim to Medicare on behalf of a Medicare beneficiary for the DME provided. Companies that sell DME and are not enrolled as a Medicare provider are not bound by the Medicare provider requirements are not required, by law, to submit a claim to Medicare on behalf of the Medicare beneficiary.
Companies that are not enrolled in the Medicare program must inform Medicare beneficiaries prior to delivery of the item that they are not enrolled as a Medicare provider and cannot bill Medicare for the item provided. This will allow the beneficiary to make an informed consumer decision on whether or not to receive the item(s) for which he or she may have to pay for "out-of-pocket."
When a company that is not enrolled in the Medicare program as an approved Medicare provider sells Durable Medical Equipment (DME) to Medicare beneficiaries, the company is required to inform the Medicare beneficiary prior to delivery of the item that they are not enrolled and cannot bill Medicare for the item provided. After the beneficiary is informed of this information and makes an informed consumer decision to purchase the item of DME from the non-enrolled company, a claim may be submitted by the beneficiary to the Medicare contractor that will process, and pay for covered services submitted by beneficiaries on a CMS-1490S Form 2.
Please be advised, we are not a Medicare Provider. If you purchase items from us that you feel are covered under under Medicare, please use the above procedures to file your claim for allowable reimbursement.