To fill out Form CMS-1490S, download the current version from the CMS website, enter your Medicare identifying information and details about each service, sign and date the form, and mail it with an itemized bill from your provider to the Medicare Administrative Contractor (MAC) that handles claims for your state. The form is one page, but it only works when the itemized bill attached to it carries every element Medicare needs, and the whole package has to reach your MAC within one calendar year of the date of service.
When This Form Is the Right One
Providers are generally required to submit Medicare claims for you. The CMS-1490S, “Patient’s Request for Medical Payment,” exists for the situations where that didn’t happen: durable medical equipment bought from a private source that doesn’t bill Medicare, foreign hospital care that qualifies for coverage, Medicare Secondary Payer situations where the provider lacks what it needs to coordinate with your other insurer, services from a sanctioned provider that Medicare has authorized to pay you directly, and non-participating providers who refuse to submit a claim even though they’re required to.
One boundary to be clear about before you start: if you signed a private contract with a provider who has formally opted out of Medicare, this form will not help you. Opt-out providers cannot bill Medicare at all, and the private contract waives your right to reimbursement. Neither Medicare nor a Medigap policy will pay.
Getting the Current Version of the Form
Download the CMS-1490S from the CMS forms page at cms.gov. It is available in English and Spanish, and the PDF is fillable, so you can type your entries before printing. You can also request a mailed copy by calling 1-800-MEDICARE (1-800-633-4227).
The accepted revision is 01/18. If you have a printed copy from an earlier year sitting in a drawer, throw it out and download a fresh one. Older versions get rejected.
Completing Each Part of the Form
The form is short. That is not an invitation to rush it. Incomplete or mismatched entries are the fastest way to have your claim bounced back weeks later.
Your Identifying Information
Enter your full legal name exactly as it appears on your red, white, and blue Medicare card. Your Medicare Beneficiary Identifier (MBI), the 11-character alphanumeric code on that card, goes in the designated field. A single wrong character means the system can’t match your claim to your account. Add your current mailing address and a daytime phone number so the MAC can reach you if something needs clarification.
Other Insurance and Accident Questions
The form asks whether you have other health coverage, such as an employer group plan, a Medigap supplemental policy, or any other plan that might be the primary payer. Answer honestly. Medicare is often the secondary payer, and failing to disclose other coverage can get the claim denied or stall it while the MAC investigates.
You will also be asked whether the illness or injury is related to a work accident, an auto accident, or another incident involving a third party. If it is, workers’ compensation or auto liability may be responsible for paying first, and Medicare needs that information before processing anything.
Signature, Date, and Representatives
You sign and date the form yourself, or an authorized representative signs for you. A representative also provides their relationship to you and their own mailing address. If someone will be handling the claim and any later appeals, CMS has a separate form, CMS-1696 (“Appointment of Representative”), that formally authorizes them to act on your behalf, receive communications, and access the medical information tied to the claim. The appointment lasts for the duration of the claim unless you revoke it.
The One-Year Deadline
Federal law requires that the claim reach Medicare no later than one calendar year after the date each service was provided. The clock runs from the actual service date, not from the end of the year. Lab work done on March 10, 2025 has to be received by March 10, 2026. Late claims are rejected with very limited exceptions, so don’t sit on the paperwork.
What the Itemized Bill Must Include
The CMS-1490S is a cover sheet. On its own it cannot be processed. You have to attach an itemized bill from the provider who treated you, and a receipt that only shows a balance or “paid in full” is not enough. The bill needs all of the following:
- The full name and street address of the doctor, facility, or supplier. Medicare checks this against its enrollment records and the Office of Inspector General’s List of Excluded Individuals/Entities. A claim tied to an excluded provider is rejected automatically.
- Each service on its own line, with the date it was performed and the place of service (office, outpatient hospital, patient’s home, and so on).
- A description of each service, ideally with CPT (Current Procedural Terminology) codes. A clear written description can work when codes aren’t on the bill, but coded bills process faster and with fewer errors.
- Diagnosis codes, usually ICD-10, that establish medical necessity. Without them, Medicare has no basis to determine coverage.
- The dollar amount charged for each individual service.
If anything on that list is missing, call the provider’s billing office and ask for a corrected itemized statement before you mail your package. Submitting an incomplete bill costs weeks.
One note if you are filing because a non-participating provider charged you directly and wouldn’t submit the claim: federal regulations cap what they can bill you at 115 percent of the Medicare fee schedule amount for non-participating suppliers, known as the “limiting charge.”1eCFR. 42 CFR 414.48 – Limits on Actual Charges of Nonparticipating Suppliers2Medicare. Does Your Provider Accept Medicare as Full Payment You pay the provider, file the CMS-1490S, and Medicare reimburses its share of the approved amount after your Part B deductible ($283 in 2026) and the standard 20 percent coinsurance.3Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles
Where and How to Mail It
The completed form and the itemized bill go to the Medicare Administrative Contractor assigned to your state. MACs are private companies that CMS contracts to process and pay Part B claims for defined geographic regions.4Centers for Medicare & Medicaid Services. Who Are the MACs The correct mailing address for your state is on the MAC Address Table printed on pages 7 through 18 of the CMS-1490S instruction packet.5Centers for Medicare & Medicaid Services. Patient’s Request for Medical Payment Mail to the wrong office and the claim gets returned or bounced around for weeks.
If the claim is for durable medical equipment, orthotics, or prosthetics, it goes to a DME MAC, not the regional A/B MAC. There are four DME MAC jurisdictions covering the country, and they are separate from the A/B MACs.4Centers for Medicare & Medicaid Services. Who Are the MACs Confirm the right address on the form instructions or at cms.gov before you seal the envelope.
Medicare does not accept the CMS-1490S electronically. No email, no upload portal. Send it by regular mail. Photocopy every page before it leaves your hands. Certified mail or a tracking service is worth the small cost for proof of delivery.
After You File
Patient-submitted claims take roughly 30 days to process. Complex situations and incomplete paperwork can stretch that out. The MAC reviews your form and the itemized bill, verifies the provider, and decides whether the services meet Medicare’s coverage rules.
Once a decision is made, you receive a Medicare Summary Notice (MSN) in the mail. The MSN is not a bill. It is a statement showing what was charged, what Medicare approved, what Medicare paid, and what you owe.6Medicare. Medicare Summary Notice If the claim is approved and you already paid the provider, a reimbursement check follows soon after.
Read the MSN carefully. The standard Part B arrangement is a $283 annual deductible followed by 20 percent coinsurance on the Medicare-approved amount for each covered service.3Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles If the math looks off, or if the claim was denied, the MSN explains the reason and tells you how to appeal.
If the Claim Is Denied
A denial is not the end. Original Medicare has a five-level appeals process.7Medicare. Appeals in Original Medicare Your first step is a redetermination, filed with the same MAC within 120 calendar days of receiving the initial determination; Medicare presumes you received the notice five days after it was mailed.8eCFR. 42 CFR Part 405 Subpart I – Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare If that fails, Level 2 is a reconsideration by a Qualified Independent Contractor. Level 3 is a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals, available when the amount in controversy meets the minimum threshold of $200 for 2026. Level 4 is a review by the Medicare Appeals Council, and Level 5 is federal district court, available when the amount in controversy is at least $1,960 for 2026.9Federal Register. Medicare Appeals Adjustment to the Amount in Controversy Threshold Amounts
Put your strongest evidence in at Level 1: a letter of medical necessity from your doctor, corrected billing codes, or documentation that the service meets coverage criteria. Most overturned beneficiary claims are won at the first or second level, not later.