If you have Medicare, you can be seen by Dr. Chapman only if you agree to sign a Private Physician Contract stating that you will not attempt to bill Medicare directly for the services he provides. Traditionally, Medicare has not paid for alternative forms of medical care anyway, and Medicare patients have traditionally paid out-of-pocket for these services. That being said, Medicare patients can sometimes receive reimbursement from Medicare secondary payers (depending on individual contracts), by filing a claim with the Medicare contractor for “denial purposes only.” Once Medicare denies the claim (because you have signed a private contract with Dr. Chapman), it can be sent on to the Medicare secondary payer. Some Medicare contractors will automatically forward the claim, and some will not. If they do not forward the claim, then you can forward the denial letter from your Medicare contractor with the claim form, to the Medicare secondary payor.
The 1490S claim form is used to file your claims to Medicare “for denial purposes only.” This Patient’s Request for Medical Payment-Form 1490S is from the Medicare website and is to be sent to Medicare in order to get a denial of your claim, which can in turn be sent to your Medicare secondary insurance carrier for possible payment. Most secondary insurance carriers want to see a denial from the primary insurance carrier (in this case Medicare) before they will process a claim. Even though Dr. Chapman has opted-out of medicare and cannot file a claim in your behalf, you may still file the forms below to obtain a Medicare denial to be forwarded to your secondary insurance carrier: