Home
Forms Library
B-3489 EX Medicare Claim Form

B-3489 EX Medicare Claim Form-2025

B-3489 EX Medicare Claim Form Preview on Page 1

Show details

4.6 out of 5

44 votes

The document is a claim form for Excellus BlueCross BlueShield, requiring members to submit completed forms along with itemized bills for medical expenses. It includes sections for member information, accident details, and other health insurance information. The form emphasizes the need for original itemized receipts and outlines what information must be included in the claims submission.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

The best way to edit B-3489 EX Medicare Claim Form in PDF format online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Working on paperwork with our extensive and user-friendly PDF editor is straightforward. Adhere to the instructions below to complete B-3489 EX Medicare Claim Form online easily and quickly:

Sign in to your account. Sign up with your credentials or register a free account to test the service prior to upgrading the subscription.
Import a document. Drag and drop the file from your device or import it from other services, like Google Drive, OneDrive, Dropbox, or an external link.
Edit B-3489 EX Medicare Claim Form. Easily add and underline text, insert images, checkmarks, and signs, drop new fillable areas, and rearrange or remove pages from your paperwork.
Get the B-3489 EX Medicare Claim Form completed. Download your updated document, export it to the cloud, print it from the editor, or share it with others via a Shareable link or as an email attachment.

Take advantage of DocHub, one of the most easy-to-use editors to quickly manage your documentation online!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get a Medicare Part D drug claim form?

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.

What form do I need for Medicare reimbursement?

Generally, youll need to submit: The completed claim form (Patient Request for Medical Payment form (CMS-1490S) The itemized bill from your doctor, supplier, or other health care provider.

What is a prescription drug claim form?

Prescription Drug Claim Form. Please use this form when you paid for a Medicare Part D covered prescription drug and are asking us to pay you back. Check your Evidence of Coverage (EOC) for more details on completing this form.

Do Medicare claims have to be submitted electronically?

The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless certain exceptions are met. Providers meeting an ASCA exception may send their claims to Medicare on a paper claim form. (For more information regarding ASCA exceptions, refer to Chapter 24.)

How to submit a receipt to Medicare for reimbursement?

How do I file a Medicare reimbursement claim? Complete Medicare Form 1490S. Get a copy of the bill you want reimbursed. Send both documents to the Medicare contractor near you.

What documents do I need to apply for Medicare Part D?

This generally includes the following: Birth certificate. Because a person needs to be at least 65 years old to enroll in Medicare, a birth certificate serves as proof of your age. Proof of U.S. citizenship or legal residency. Social Security card. Health insurance information. Tax information. Military documents.

B-3489 EX Medicare Claim Form-2025

Here's how it works

The best way to edit B-3489 EX Medicare Claim Form in PDF format online

Complete this form in 5 minutes or less

Got questions?

How do I get a Medicare Part D drug claim form?

What form do I need for Medicare reimbursement?

What is a prescription drug claim form?

Do Medicare claims have to be submitted electronically?

How to submit a receipt to Medicare for reimbursement?

Complete this form in 5 minutes or less

People also ask

What documents do I need to apply for Medicare Part D?

Try more PDF tools

B-3489 EX Medicare Claim Form-2025

Here's how it works

The best way to edit B-3489 EX Medicare Claim Form in PDF format online

Complete this form in 5 minutes or less

Got questions?

How do I get a Medicare Part D drug claim form?

What form do I need for Medicare reimbursement?

What is a prescription drug claim form?

Do Medicare claims have to be submitted electronically?

How to submit a receipt to Medicare for reimbursement?

Related Searches

Related forms

Complete this form in 5 minutes or less

People also ask

What documents do I need to apply for Medicare Part D?

Try more PDF tools