Forms catalog for Medicare Part B

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 B Redetermination and Clerical Error Reopening Request Form - Fill and Print (FP152)

Note: If you are appealing a Part A service under a document control number (DCN) use the Part A form found here. (DCNs include alpha characters (e.g., 123456789100101PAA))

A request for a clerical error reopening would be submitted to correct minor errors or omissions of claim specific information.

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.

Note: For a fast and easy way to submit a clerical error reopenings, or claim corrections, we encourage you to use Novitasphere or the automated claim corrections IVR.

*Fax or Mail this form - faxes are preferred!
Click for Jurisdiction L mailing addresses

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Request for Reconsideration by a Qualified Independent Contractor (QIC) (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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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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CMS Forms List

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

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-855I - Physicians and Non-Physician Practitioners

Designed for the individual provider.

Instructions

CMS-855B - Clinics/Group Practices and Certain Other Suppliers 

Designed for groups and organizations.

Instructions

Electronic Data Interchange (EDI) 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 processing before 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) 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. Not for enrollment in Novitasphere portal. Please allow 10 business days for processing before 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 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 processing before 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 processing before 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 B 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-855B - Clinics/Group Practices and Certain Other Suppliers

Clinics and group practices can apply for enrollment in the Medicare program or make a change to their existing enrollment information using the CMS-855B. Complete this application if you are an organization / group that plans to bill Medicare and you are:

A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, and portal x-ray suppliers).

A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.

Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction.

Currently enrolled in Medicare and need to make changes to your existing enrollment data.

This 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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CMS-855I - Physicians and Non-Physician Practitioners

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855I. Complete this application if you are an individual practitioner who plans to bill Medicare and you are:

An individual practitioner who will provide services in a private practice.

An individual practitioner who will provide services in a group setting.

Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction.

Currently enrolled in Medicare and need to make changes to your existing enrollment information.

An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you’re the sole owner.

This 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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CMS-855O - Ordering and Referring Physicians and Non-Physician Practitioners

Physician and non-physician practitioners can apply to register for the sole purpose of ordering and referring items and/or services to Medicare beneficiaries or make a change in their registration using the CMS-855O. These physicians and non-physician practitioners do not and will not send claims to a Medicare administrative contractor for the services they furnish for reimbursement.

This 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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CMS-855R - Reassignment of Medicare Benefits

Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries or are terminating a currently established reassignment of benefits. Reassigning your Medicare benefits allows an eligible organization / group to submit claims and receive payment for Medicare Part B services that you have provided as a member of the organization/group. Such an eligible organization / group may be an individual, a clinic / group practice, or other health care organization. A separate CMS-855R must be submitted for each organization / group where a reassignment is being established or terminated.

Note: Physician assistants and sole owners do not complete the CMS-855R application for reassignment because the information is reported on the CMS-855I application.

This 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 Electronic Funds Transfer (EFT) (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.

Included copy of voided check or bank letterhead

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Medicare Participating Physician or Supplier Agreement (CMS-460)

Used to enroll or change your participating status with the Medicare program.

Opt-Out Affidavit to Opt-Out of Medicare 

Section 1802 of the Act, as amended by §4507 of the Balanced Budget Act (BBA) of 1997, permits a physician or practitioner to opt-out of Medicare and enter into private contracts with Medicare beneficiaries. In order for a private contract with a beneficiary to be effective, the physician/practitioner must file an opt-out affidavit with all Medicare carriers to which he / she would submit claims, advising that he / she has opted out of Medicare.

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

Financial Statement of Debtor (CMS-379)

This form is used by a provider that is a sole proprietor to request and extended repayment plan for an overpayment debt.

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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 B (8322)

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.

CAAP Debt Dispute form

This form is required by CMS when submitting a CAAP Dispute

Please complete the form in its entirety.

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 do 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.

Prior authorization request for repetitive, scheduled, non-emergent ambulance transports Medicare Part B fax/mail cover sheet

This coversheet can be used to request prior authorization for repetitive, scheduled, non-emergent ambulance transports. Please send physician-signed Physician Certification Statement (PCS) and supporting medical documentation along with coversheet.

View instructions for completing the form

Influenza (Flu) vaccine roster form

The influenza vaccine roster form allows you to report five patients per page and is acceptable to submit up to 20 single-sided pages per modified CMS-1500 (2-12) claim form for a total of 100 beneficiaries.

Claims will be returned as unprocessable when the standard roster billing forms are not submitted with the modified CMS-1500 (02/12) claim form or if the roster billing form/CMS-1500 claim form are incomplete.

Roster billing for Part B providers

Pneumococcal vaccine roster form

The pneumococcal billing form allows you to report five patients per page and is acceptable to submit up to 20 single-sided pages per modified CMS-1500 (2-12) claim form for a total of 100 beneficiaries.

Claims will be returned as unprocessable when the standard roster billing forms are not submitted with the modified CMS-1500 (02/12) claim form or if the roster billing form/CMS-1500 claim form are incomplete.

Roster billing for Part B providers

COVID-19 vaccines or monoclonal antibody infusion roster form

The COVID-19 vaccines or monoclonal antibody infusion roster form allows you to report five patients per page and is acceptable to submit up to 20 single-sided pages per modified CMS-1500 (2-12) claim form for a total of 100 beneficiaries.

Please separate the billing of COVID-19 vaccine form from the monoclonal antibody form.

Roster billing for Part B providers

Evaluation and Management (E&M) Score Sheet (8985)

Sheets used to "score" provider's evaluation and management services.

Health Insurance Claim Form SAMPLE (CMS-1500)

All paper claims you submit on behalf of your Medicare patients must be submitted using the CMS-1500 claim form. The CMS-1500 claim form specifications require red drop out ink in order to facilitate the use of image processing technology such as optical character recognition (OCR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The CMS claim forms may be purchased from local printers or through the following organizations:

U. S. Government Printing Office
Superintendent of Documents
Washington, DC 20402
(202) 512-1800 (Pricing Desk)

Fax- (202) 512-2250

or

Order Department
AMA
P.O. Box 109050
Chicago, IL 60610-9050

American Express, Visa and Master Card orders may be placed by calling 1-800-621-8335.

This is the only format that is accepted. Photocopies or Xerox copies of the form will not be processed. Refer to CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 26 or Completion of CMS-1500 (02-12) Claim Form for more information on completing this form.

HMO Copayment Receipt Form

This form is used by providers to request secondary payment when the primary payer is an employer-sponsored health maintenance organization (HMO).

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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

MLN Matters article MM6698, Signature guidelines for medical review purposes