CMS Pub. 100-04, ch. 1, § 70.8.4

A number of prescribed claims forms have been developed for use when requesting

payment for Part B Medicare services. Many are printed and distributed nationally free

of cost through CMS’s Printing and Publications Branch. (See NOTE below for

exception.)

In order to maintain control over the content and format of the forms, private printing of a

Government form is not routinely permitted. However, if you or another organization

wishes to independently print a prescribed claims form, the reproduction of a claims form

must be in accordance with §422.527 of Title 20, Chapter III, Part 422 of the Code of

Federal Regulations. Obtain CMS approval for printing a prescribed form. Route the

written request for approval through the RO. Include the following:

• The reason or need for such reproduction;

• The intended user of the form;

• The proposed modifications or format changes, with printing or other

specifications (such as realignment of data or line designations);

• The type of automatic data processing machinery, if any, for which the form

is designed; and

• Estimates of printing quantity, cost per thousand, and annual usage.

NOTE: This procedure does not apply to the Form CMS-1500, Health Insurance Claim

Form. A/B MACs (B), physicians and suppliers are responsible for purchasing

their own forms. This form can be bought in single, multipart snap-out sets or

in continuous pin-feed format. Medicare accepts any version. Forms can be

obtained from local printers or printed in-house as long as it follows the CMS

approved specifications developed by the National Uniform Claim Committee.

The Form CMS-l490 was formerly the basic Part B claims form. It was replaced by

Form CMS-l500 for claims completed by physicians and suppliers (except ambulance

suppliers), and Form CMS-l490S for claims from beneficiaries. You must, however,

continue to accept and process claims received on Form CMS-1490 form after conversion

to Forms CMS-l500 and CMS-l490S.

The Form CMS-1500 (Health Insurance Claim Form) is the prescribed form for claims

prepared and submitted by physicians or suppliers (except for ambulance services),

whether or not the claims are assigned. It can be purchased in any version required i.e.,

single sheet, snap-out, continuous, etc.

The forms described below are printed and distributed to contractors by CMS and are

available in single sheets, multipart snap-out sets, or in pin-feed format.

The Form CMS-1490S (Patient's Request for Medical Payment) form is used only by

beneficiaries (or their representatives) who complete and file their own claims. It

contains the patient’s comparable items of data that are on the Form CMS-1500. When

the Form CMS-1490S is used, an itemized bill must be submitted with the claim. Social

Security Offices use the Form CMS-1490S when assisting beneficiaries in filing Part B

Medicare claims. For Medicare covered services received on or after September 1, 1990,

the Form CMS-1490S is used by beneficiaries to submit Part B claims only if the service

provider refuses to do so. Inasmuch as the Form CMS-1490S has no provision for a

diagnosis code, the diagnosis code is not required at the time of claim submission.

CMS implemented a new version of the Form CMS-1490S effective January 1, 2019.

The revised form is version 01/18, OMB control number 0938-1197. The revised form

will replace the previous version of the form 01/05, OMB control number 0938-0999.

The term, “Form CMS-1490S” refers to the form generically, independent of a given

version.

Medicare will conduct a dual-use period (January 1, 2019 through March 31, 2019)

during which Beneficiaries (or their representatives) can send Medicare claims on either

the old or the revised form. When the dual-use period is over, Medicare will accept

beneficiary paper claims on only the revised Form CMS-1490S, version 01/18.

The Form CMS-1556 (Prepayment Plan for Group Practices Dealing Through An A/B

MAC (B)) is used by plans which, for Medicare purposes are, both Group Practice

Prepayment Plans, and are paid on the basis of reasonable charges related to their costs

for furnishing services to their subscribers.