Form Assistance

PDF File Downloading Technical Assistance

Due to varying Internet Browsers and versions of Adobe, the following activities may be used to assist those who may have difficulty initially opening Portable Document Format (PDF) files and forms from this website.

  1. Error message, "Adobe PDF Document. There is a problem with Adobe Acrobat/Reader. If it is running, please exit and try again. (0:104)."
    • Users may select "OK" from error message and then use their Internet Browser "refresh" command or Function F5 key to attempt to open PDF file
  2. Users are encouraged to update their version of Adobe Reader This link takes you to an external website.. Noridian PDFs are traditionally backward-compatible by two versions
  3. Disable PDF display in browser option. PDF Help Display PDF in browser | Acrobat DC, Acrobat Reader DC This link takes you to an external website..
  4. Right-click hyperlink title of PDF and select "Save as.…" to save a local copy of PDF file. Navigate to location file has been saved and then open file with Adobe Reader.

Interactive Form Information

The interactive forms on the Noridian site require Adobe Acrobat Reader 6.0 or higher. 

Interactive Form Tips

  1. Content entered within form can only be printed; content entered can not be saved. The interactive form allows ease in completion by user and clarity when received at Noridian.
  2. Select "Highlight fields" and/or "Highlight required fields" box to view editable fields and assure form is completed in its entirety
  3. Use mouse to hover over editable fields to receive supplemental instructions. CMS supplied instructions are also included with most forms
     

Advance Beneficiary Notice of Noncoverage (ABN) Forms

General Written Inquiry Forms

Other Review Entity Forms

Universal

Comprehensive Error Rate Testing (CERT)

Recovery Auditor (RAC)

  • There are no specific RAC related forms, see Universal forms

Supplemental Medical Review Contractor (SMRC)

  • There are no specific SMRC related forms, see Universal forms

UB-04 (CMS-1450) Form

The CMS-1450 form (UB-04) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from ASCA requirement for electronic submission of claims.

Original UB04 claim forms can be obtained from U.S. Government Printing Office

Assistant Superintendent
Department of Acct Rep Division
USGPO Room C-830
Washington, DC 20401

See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 25 This link will take you to an external website. for general form completion instructions.

Submit paper claims to appropriate state address indicated on Mailing Addresses webpage.