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Form CMS-1490 (version 01/18)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
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
Form Approved OMB
No. 0938-1197
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
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Form CMS-1490 (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
No Employment
Yes
No Auto Accident
Yes
No Treatment for chronic dialysis or kidney transplant
Yes
No 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
No Are you employed and covered under an employee health plan?
Yes
No Is your spouse employed and are you covered under your spouse’s employee health plan?
Yes
No 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.
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Form CMS-1490 (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.
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Form CMS-1490 (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.
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.
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.
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.
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.
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).
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Form CMS-1490 (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.
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):
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.
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.
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.
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 physicia
shipboard service
n is legally authorized to practice where he or she furnished the services
For
s please include a copy of the ship’s itinerary.
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Form CMS-1490 (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
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)
• Check the appropriate box for the patient’s sex.
• Furnish your mailing address and include your telephone number
Section 2 – INFORMATION ABOUT SERVICES FURNISHED
• Describe the illness or injury for which you received treatment
• Patient’s Condition related to: Check the appropriate boxes
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:
• 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
• The ordering & referring Providers Full Legal Name
and address if required as indicated in Section 2
• 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.
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Form CMS-1490 (version 01/18)
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:
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
(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
Arizona
Noridian Healthcare Solutions , LLC
P.O. Box 6704
Fargo, ND 58108-6704
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
(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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
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:
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
(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
Maine
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
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:
Novitas Solutions, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
Massachusetts
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
(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
Missouri
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
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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
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, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
New Mexico
Novitas Solutions
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
New York
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
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
Oklahoma
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
Noridian Healthcare Solutions
P.O. Box 6702
Fargo, ND 58108-6702
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
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
Novitas Solutions
P.O. Box 3108
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
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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
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:
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
FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS) ONLY
If you live in:
Mail your form and supporting documentation to:
Connecticut, Delaware, District of Columbia, Maine,
Maryland, Massachusetts, New Hampshire, New Jersey,
New York, Pennsylvania, Rhode Island, Vermont
Noridian JA
P.O. Box 6780
Fargo, ND 58108-6780
Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio,
Wisconsin Indianapolis, IN 46207-7027
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
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
P.O. Box 6727
Fargo, ND 58108-6727
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live in:
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
(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
Arizona
Noridian Healthcare Solutions , LLC
P.O. Box 6704
Fargo, ND 58108-6704
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
(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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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14
Form CMS-1490 (version 01/18)
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
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
(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
Maine
National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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15
Form CMS-1490 (version 01/18)
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live 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:
Novitas Solutions, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
Massachusetts
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
(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
Missouri
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
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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
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
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, Inc.
Attention: Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
New Mexico
Novitas Solutions
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
New York
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
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
Oklahoma
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
Noridian Healthcare Solutions
P.O. Box 6702
Fargo, ND 58108-6702
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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17
Form CMS-1490 (version 01/18)
FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES
If you live 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
Novitas Solutions
P.O. Box 3108
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
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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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Form CMS-1490 (version 01/18)
If you live in:
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
MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
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FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES