Forms - JA DME

• ABN - CMS-R-131
• ABN Instructions
• ABN Tutorial

General

• CMS-1696 - Appointment of Representative
• CMS 20031 - Transfer (Assignment) of Appeal Rights
• Documentation Checklists

Redetermination - (First level)

• CMS 20027 - Medicare Redetermination Request
• Medicare DME Redetermination Request
  • Redetermination Completion Guide
  • Redetermination Request Checklist

Reconsideration - (Second level)

• CMS 20033 - Medicare Reconsideration Request

Administrative Law Judge (ALJ) Hearing - (Third level)

• OMHA-100 & OMHA-100A Forms

Medicare Appeals Council Review (Departmental Appeals Board (DAB)) - (Fourth level)

• Appeal Form DAB-101

This form is the prescribed form for claims prepared and submitted by physicians or suppliers. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800.

• CMS-1500 Claim Form Instructions
• CMS-1500 Claim Form Tutorial

• DME Individual Education Request Form - Request a one-on-one virtual visit with a DME Education Representative
• DME Provider Outreach and Education Advisory Group JA Membership Application - Apply to be a member of the DME POEAG to assist Noridian in the creation, implementation, and review of Noridian's provider education and training strategy and efforts
• Speaker Request Form for DME Events - Request Noridian's DME Outreach and Education team participation at your event

• CMS 588 - Electronic Fund Transfer Authorization
• CMS 855S - Enrollment Application

• Freedom of Information Act (FOIA) Request

• MSP Overpayment Refund Form - Refund related to MSP claim
  • MSP Overpayment Refund Spreadsheet - Subsequent attachment to above form
• Medicare Secondary Payer
• Medicare Secondary Payer Questionnaire - Use to facilitate identification and proper billing of MSP cases. Beneficiary or registration personnel may complete

• Paperwork (PWK) Fax/Mail Coversheet
• Review Contractor Correspondence Tracking
• Signature Attestation Statement
• Suggested Intake

Comprehensive Error Rate Testing (CERT)

• Provider CERT POC

• Advance Determination of Medicare Coverage (ADMC) Coversheet
• DME Prior Authorization Collaborative Education Request Form
• Prior Authorization Request for Durable Medical Equipment Coversheet

• Accelerated and Advance Payment Form
• CMS 379 - Financial Statement of Debtor
• Extended Repayment Schedule (ERS) Request
• ERS Amortization Schedule
• Immediate Recoupment/Offset - When requesting immediate recoupment before automatic offset
• MSP Overpayment Refund Form - Refund related to Medicare Secondary Payer (MSP) claim
  • MSP Overpayment Refund Spreadsheet - Subsequent attachment to above form for multiple requests
• Non-MSP Voluntary Refund Checks Form - Submit a refund not related to MSP - use when enclosing a check
  • Non-MSP Overpayment Refund Spreadsheet - Subsequent attachment to above form for multiple requests
• Instructions Non-MSP Overpayment Refund Request - to submit an overpayment request not related to MSP - use when not enclosing a check

• Medicare DME Reopening Request
  • Reopening Completion Guide
  • Reopening Request Checklist

• Medicare Claims Processing System DDE/PPTN/CSI User Request