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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

Forms Catalog for Medicare Part A

This page contains downloadable copies of paper forms. Download them to your computer, print them on your printer, and follow instructions as indicated on each form.

NOTE: Due to CMS security requirements, our forms are provided only in Adobe's PDF file format. You can download a free reader at the Adobe web site. Some may be external to Novitas Solutions (provided from an outside source such as CMS).

Beneficiary Notices Initiative (BNI)

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Description

Notes

Instructions

Hospital-Issued Notices of Noncoverage (HINNs)

Hospitals should provide HINNs to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it is:

   

Skilled Nursing Facility Advance Beneficiary Notice

Skilled Nursing Facilities (SNFs) must issue a liability notice to Original (fee for service) Medicare beneficiaries before the SNF provides:

an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or
custodial care.
   

Appeals Forms

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Description

Notes

Instructions

Part A Redetermination and Clerical Error Reopening (FP1000)

PART A - First Level Appeal Form. Use this form to appeal an initial claim determination. Do not use this form to submit a 2nd level (QIC) appeal request.

*Fax or Mail this form – faxes are preferred!

View Tutorial

Appointment of Representative (CMS-1696)

This form must be completed by a Medicare beneficiary / provider or supplier if he / she chooses to have an Appointed Representative. The assigned person will act as the representative of the beneficiary / provider / supplier for an appeal of a claim(s).

The beneficiary, provider, or supplier is authorizing their representative to make or give any request or notice; to present or to elicit evidence; to obtain information; and to receive any notice in connection with the claim or claims in question.

 

View Tutorial

Request for Reconsideration by a QIC (Qualified Independent Contractor) (CMS-20033)

Effective for Redetermination Notices dated on or after January 1, 2006, if you wish to request a second level appeal, it must be submitted to a QIC. This form should be used for QIC requests.

For filing second level appeal

View Tutorial

EDI (Electronic Data Interchange) Forms

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Description

Notes

Instructions

EDI (Electronic Data Interchange) Enrollment Form 8292JH


Providers wishing to enroll for electronic billing, or who need to make a change to their existing electronic billing set up, must complete an EDI Enrollment form. Not for enrollment in Novitasphere portal. Please allow 10 business days before contacting EDI Services for a status of electronic billing forms sent for processing.

Please fax to the number located on the form.

Instructions

EDI (Electronic Data Interchange) Third Party Enrollment Form 8291JH

Software vendors, billing services or clearinghouses wishing to enroll for electronic billing, or who need to make a change to their existing electronic billing set up, must complete a Third Party Enrollment form. This form should not be completed by providers. Not for enrollment in Novitasphere portal. Please allow 10 business days before contacting EDI Services for a status of electronic billing forms sent for processing.

Please fax to the number located on the form.

Instructions

Electronic Data Interchange (EDI) Portal Enrollment Form 8292PJH

Providers wishing to enroll for assess to Novitasphere Portal, our free, web-based portal. For full details regarding Novitasphere, visit our Novitasphere Portal Center.

Please fax to the number located on the form. 

Instructions

Third Party Novitasphere Portal Enrollment form 8291PJH

Billing Services and Clearinghouses wishing to enroll for access to Novitasphere Portal, our free, web-based portal. For full details regarding Novitasphere, visit our Novitasphere Portal Center.

Please fax to the number located on the form. 

Instructions

ERA (Electronic Remittance Advice) Exception Request Form

This form is used by electronic billers to request the Standard Paper Remittance.

Please fax to the number located on the form.

Instructions

EDI Fax Cover Sheet 

This form should only be used to fax general EDI correspondence to EDI Services.

The EDI fax Cover Sheet is not to be used for Medical Documentation when submitting an electronic claim. Please review the Fax Cover Sheet for Submitting Medical Documentation for Electronic Claims below.

Do not send with EDI enrollment forms.

Please fax to the number located on the form.

 

Fax Cover Sheet for Submitting Medical Documentation for Electronic Claims (PWK) - PART A Form

When a paper attachment is required to adjudicate an electronic claim, EDI billers should complete this form. The completed form and attachment must be faxed within 7 calendar days of claim submission, or mailed 10 calendar days after submitting an electronic claim that contains the PWK segment.

Please fax to the number located on the form.

Instructions

ABILITY | PC-ACE CD-ROM Request Form

This form is used to request the Medicare electronic billing software by CD-ROM.

Must be mailed to the address located on the bottom of the form.

Instructions

EDI Submitter ID Update Request Form

This form is used to update the information we have on file to mail you EDI-related documents,

Please fax to the number located on the form.

Instructions

EDI Portal Submitter ID Update Request Form

This form is used to update the information we have on file to mail you EDI-related documents to your Portal Submitter ID, or update your Security Official / Backup Security Official.

Please fax to the number located on the form. 

 

Form Status and Verification Inquiry Tool

Request status of EDI Enrollment / EDI Portal form.

This tool is only for EDI Enrollment form status / verification. No other questions should be sent using this tool.

The form is electronically submitted.

Complete this form in its entirety.

Enrollment Forms

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Description

Notes

Instructions

CMS-855A - Institutional Providers

Institutional providers can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855A. Complete this application if you are a health care organization and you plan to bill Medicare for Part A medical services or would like to report a change to your existing Part A enrollment data.

This enrollment form can be printed and submitted to Novitas Solutions, but it must be submitted with original signatures. Please utilize the Tutorial to ensure accurate completion.

 

View Tutorial

Authorization Agreement for EFT (Electronic Funds Transfer) (CMS-588)

This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking. This form can be printed and submitted to Novitas Solutions, but it must be submitted with original signatures.

This enrollment form can be printed and submitted to Novitas Solutions, but it must be submitted with original signatures. Please utilize the Tutorial to ensure accurate completion.

Included copy of voided check or bank letterhead

View Tutorial

Provider Enrollment Application Cover Sheet (for Indian Health Services)

Please include coversheet with enrollment form.

 

Where to Send

Financial & Overpayment / Refund Forms

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Description

Notes

Instructions

Accelerated Payment Form

This form is to be completed by a Medicare Part A provider if they choose to request an Accelerated Payment.

   

Immediate Recoupment Request Form 

To assist you in providing complete information for your immediate recoupment requests.

 

View Tutorial

Return Of Monies To Medicare - Part A (8322-1A)

Providers should send us this updated form to facilitate prompt and accurate credit of unsolicited monies or voluntary refunds to Medicare.

Please complete the form in its entirety.

 

Return Of Monies To Medicare - Part A Indian Health Services (FP 171)

Providers should send us this updated form to facilitate prompt and accurate credit of unsolicited monies or voluntary refunds to Medicare.

Please complete the form in its entirety.

View Tutorial

Medicare Credit Balance Certification (CMS-838)

This is the form that all providers who are obligated to file a credit balance report must use each quarter. It includes the certification page, the 838 detail page, and instructions on how to complete the form. 

   

All other forms

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Description

Instructions

New FISS Access (Providers)

Change to FISS Access (Providers)

For requesting new access or a change in access to the FISS (Fiscal Intermediary Standard System).

View Tutorial

Hardcopy Adjustment and Cancel Request Form

This form is used when submitting cancels and adjustments on hardcopy UB-04 CMS-1450 Claim Forms. It should be attached to the UB-04 CMS–1450 claim form. Electronic adjustment and cancel requests are preferred.

View Tutorial

HIPAA Compliant Authorization For The Release of Patient Information Pursuant To 45 CFR 164.508

The form may be utilized to complete a valid HIPPA (Health Insurance Portability and Accountability Act) compliant authorization when requesting records for someone other than yourself. The authorization contains the core elements and required statements necessary to be honored under the FOIA (Freedom of Information Act). Please print the form, complete all information, and mail / fax with your FOIA request.

 

Request For Assistance (RFA) Documentation Support Form

Only submit this form when requested by the MAC. The Request For Assistance (RFA) Documentation Support Form is used by providers to submit admit / discharge records to assist with claim adjudication of Reason Code U5601

 

Paper Claim Submission Form (CMS-1450) (UB-04)

The CMS-1450 (UB-04) form is used by institutional and other selected providers to complete a Medicare Part A paper claim for submission to Medicare Fiscal Intermediaries. (Note: This PDF is not 100% to scale.)

If you intend to make paper copies of the Form CMS-1450 (in PDF) for claims submission purposes, please contact the specific health care payer that you intend to submit these claims to before submitting these claims for payment. Some payers may be able to accept a black & white copy of Form CMS-1450. Other payers may not accept a black & white copy if they are utilizing OCR (Optical Character Recognition) equipment.

Where to Send

Sample Signature Attestation Statement

An attestation statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.

Reference:

Medicare Learning Network Matters Article MM6698
 

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Last modified:  10/04/2017