Forms Catalog for Medicare Part A

Advance Beneficiary Notice (ABN) Form (CMS-R-131)

The ABN is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied.

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!

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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.

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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

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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:

Both enrollment and changes of practice addresses are reported on the applicable CMS-855 form.

Changes can include, but are not limited to: adding a new location, moving to a new location, or changing the suite number of current location.

CMS-855A - Institutional Providers

Designed for Part A providers

Instructions

CMS Forms List

A list that provides access and/or information for many CMS forms.

EDI (Electronic Data Interchange) Enrollment Form (8292)

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 for processingbefore contacting EDI Services for status of your form. Please do not send duplicate forms.

Please fax to the number located on the form.

Instructions

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

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 for processingbefore contacting EDI Services for status of your form. Please do not send duplicate forms.

Please fax to the number located on the form.

Instructions

Electronic Data Interchange (EDI) Portal Enrollment Form (8292P)

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 allow 10 business days for processingbefore contacting EDI Services for status of your form. Please do not send duplicate forms.

Please fax to the number located on the form. 

Instructions

Third Party Novitasphere Portal Enrollment form (8291P)

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 allow 10 business days for processingbefore contacting EDI Services for status of your form. Please do not send duplicate forms.

Please fax to the number located on the form. 

Instructions

Novitasphere Portal Migration List

Attach this list with your 8291P form to request the conversion of multiple PTANs (Provider Transaction Access Numbers). 

Must be submitted with a completed Third Party Novitasphere Portal Enrollment form (8291P) or EDI Fax Cover Sheet (FP159) 

Follow instructions on page 2 of the Novitasphere Portal Migration List.

EDI Fax Cover Sheet (FP159) 

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

EDI Submitter ID Update Request Form (FP167)

This form is used to update the information we have on file related to your EDI Submitter ID.

Please fax to the number located on the form.

Instructions

EDI Portal Submitter ID Update Request Form (FP167P)

This form is used to update the information we have on file related to your Novitasphere Portal submitter ID, including updates to the Office Approver/Office Backup Approver.

Please fax to the number located on the form. 

 Instructions

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.

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.

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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

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Provider Enrollment Application Cover Sheet (for Indian Health Services)

Please include coversheet with enrollment form.

Where to Send

Accelerated Payment Form

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

Extended Repayment Plan (ERP) Form - Not a Sole Proprietor

This form is a checklist of information that is required by CMS.

Instructions

Extended Repayment Plan (ERP) Form - Sole Proprietor

This form is a checklist of information that is required by CMS.

Instructions

Immediate Recoupment Request Form 

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

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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.

Medicare Credit Balance (CMS-838) Detail Page, Certification Page & Instructions

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. 

Patient's Request for Medical Payment (CMS-1490S)

CMS-1490S (Patient's Request for Medicare Payment) is used by Medicare beneficiaries for submitting Medicare covered services. If a beneficiary wishes to submit a claim, he or she must use the CMS-1490S form. A beneficiary must also attach to the CMS-1490S form any bill (s) he or she receives from providers/suppliers.

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Prior authorization request hospital outpatient procedures Medicare Part A fax/mail cover sheet

The hospital outpatient department (OPD), or provider on behalf of the hospital OPD, must submit the PAR for certain hospital OPD services. For details refer to Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services

Prior authorization request hospital outpatient procedures expedited Medicare Part A fax/mail cover sheet

NOTE: A prior authorization request is considered expedited only when the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary.

FISS Enrollment Application

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

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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.

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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

Long Term Care Hospital (LTCH) Site Neutral Dispute Form

Per SE1627, standard payment can be made to a Long Term Care Hospital  (LTCH) when specific criteria is met. When a LTCH disagrees with the site neutral payment, the LTCH shall collect the appropriate records from the immediately preceding hospital. The LTCH shall use the Long Term Care Hospital (LTCH) Site Neutral Dispute Form to submit the immediately preceding hospital records and their own records to demonstrate that the applicable criteria for exclusion from the site neutral payment rate have been met.

View Article "Long Term Care Facility Prospective Payment System Standard versus Site Neutral Payment"