Forms - JA DME
Forms
Access common Medicare forms and view tips for downloading and completing interactive forms below. See all CMS forms on the CMS Forms page.
- Advance Beneficiary Notice of Noncoverage (ABN)
- Appeals
- CMS-1500 Claim Form
- Educational
- Enrollment
- Freedom of Information Act (FOIA)
- Medicare Secondary Payer (MSP)
- Miscellaneous
- Pre-Claim Review
- Refunds/Overpayments
- Reopening
- User Provisioning (Claim Status Inquiry Support)
Correspondence may be sent via fax, esMD, mail, or via CD, DVD, or USB. See the Options for Submitting Documentation page for more information.
Advance Beneficiary Notice of Noncoverage (ABN) Forms
Appeal Forms
General
- CMS-1696
- Appointment of Representative
- CMS 20031
- Documentation Checklists
Redetermination - (First level)
- CMS 20027
- Medicare DME Redetermination Request [PDF]
Reconsideration - (Second level)
- CMS 20033
Administrative Law Judge (ALJ) Hearing - (Third level)
Medicare Appeals Council Review (Departmental Appeals Board (DAB)) - (Fourth level)
CMS-1500 Claim Form
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.
Educational Request Forms
- DME Individual Education Request Form [PDF] - Request a one-on-one virtual visit with a DME Education Representative
- DME Provider Outreach and Education Advisory Group JA Membership Application [PDF] - 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 [PDF] - Request Noridian's DME Outreach and Education team participation at your event
Freedom of Information Act (FOIA) Form
Medicare Secondary Payer (MSP) Forms
- MSP Overpayment Refund Form [PDF] - Refund related to MSP claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form
- Medicare Secondary Payer [PDF]
- Medicare Secondary Payer Questionnaire [PDF] - Use to facilitate identification and proper billing of MSP cases. Beneficiary or registration personnel may complete
Miscellaneous Forms
- Paperwork (PWK) Fax/Mail Coversheet [PDF]
- Review Contractor Correspondence Tracking [Excel]
- Signature Attestation Statement [PDF]
- Suggested Intake [PDF]
Comprehensive Error Rate Testing (CERT)
- Provider CERT POC [PDF]
Refunds/Overpayments Forms
- Accelerated and Advance Payment Form [PDF]
- CAAP Debt Dispute Form [PDF]
- CMS 379
- ERS Amortization Schedule [Excel]
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Recoupment/Offset [PDF] - When requesting immediate recoupment before automatic offset
- MSP Overpayment Refund Form [PDF] - Refund related to Medicare Secondary Payer (MSP) claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
- Non-MSP Voluntary Refund Checks Form [PDF] - Submit a refund not related to MSP - use when enclosing a check
- Non-MSP Overpayment Refund Spreadsheet [Excel] - 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
Reopening Form
User Provisioning (Claim Status Inquiry Support) Form
Form Assistance
PDF File Downloading Technical Assistance
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Interactive Form Tips
Select "Highlight fields" and/or "Highlight required fields" to ensure all form fields are completed.
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