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.
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 physician is legally authorized to practice where he or she furnished the services
For shipboard services please include a copy of the ship’s itinerary.
Form CMS-1490S (version 01/18)