Cms1490s 2025

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CMS 1490S. Form Title. PATIENTS REQUEST FOR MEDICAL PAYMENT (English/Spanish)
Your Medicare Part A and B claims are submitted directly to Medicare by your providers (doctors, hospitals, labs, suppliers, etc.).
How to fill out the Medicare Reimbursement Account Claims Instructions? Register for your MRA account at fepblue.org/mra. Complete the online claim form with your details. Upload proof documents verifying your Medicare Part B premium payment. Submit your claim and wait for processing updates.
Form CMS-1696 can be downloaded at .cms.gov or obtained by calling the Customer Service number on your member ID card. The claim may be submitted via mail or fax to the address or phone number on the Medicare Part D Prescription Drug Claim Form.
How do I file a claim? You can download and fill out a form, called the Patient Request for Medical Payment form (CMS-1490S). This form is also available in Spanish.
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If you have Original Medicare, youll need to mail your claim form, itemized bill and supporting documents to the address for your state, which is listed on the Medicare Administrative Contractor Address Table within the claim form.
If you receive a settlement, judgment, award, or other payment related to this claim and Medicare determines that it has made conditional payments that must be repaid, you will get a demand letter.

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