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Forms & Checklists

Use the forms and coversheets below for submitting information to the JB DME MAC. The checklists, beneficiary questionnaires, and samples of attestation statements and notifications are useful in gathering information to document certain DMEPOS requirements. Mailing addresses and fax numbers are listed on the JB Contact Information page and/or the form/coversheet.

Visit CMS FormsExternal Website for a complete list of CMS forms.

Note:Visit the Guides & Charts page for charts, job aids, and guides to help suppliers navigate Medicare claims, documentation requirements, and appeals.

Title

Description/Additional Information

Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131External Website (English and Spanish forms are located under Downloads)

Used in situations where Medicare payment is expected to be denied. Keep a copy of the ABN on file to make available upon request. Visit Advance Beneficiary Notices (ABNs) for more information.

Advanced Determination of Medicare Coverage (ADMC) RequestPDF

Submit an ADMC request to the DME MAC for prior approval of customized wheelchairs before delivery. This is a voluntary program. Visit Advanced Determination of Medicare Coverage (ADMC) for more information.

Appeals (1st Level): Claim Redeterminations

1st Level of Appeal – submit to the DME MAC.

If you need to send more than one redetermination request in a single fax transmission, you can do so with the Redetermination Request Separator SheetPDF. Whether you have two, three, or more separate redetermination requests, simply insert the separator sheet in between each of the requests in your fax. When CGS receives the fax, our scanning technology will detect the separator sheet and know to separate each section of the fax automatically.

Appeals (2nd Level): Claim Reconsideration

Reconsideration Request FormPDF

2nd Level of Appeal – submit to Quality Independent Contractor (QIC).

Visit The 5 Levels of the Appeals Process for more information.

Beneficiary Intake QuestionnairePDF (Suggested Intake Form)

Build a strong intake process by gathering information from the beneficiary about same or similar equipment, basic eligibility information, other insurance, and ordering practitioner information.

Capped Rental and Inexpensive or Routinely Purchased Items Notification (Purchase Option Letter)External PDF

An example of a purchase option letter to notify the beneficiary of the option to purchase or rent capped rental items. Visit DME MAC Jurisdiction B Supplier Manual, Chapter 5PDF for more information.

Certificate of Medical Necessity (CMNs)

CMS is discontinuing the use of CMNs and DIFs for dates of service on or after January 1, 2023. For services on or after January 1, 2023, Common Electronic Data Interchange (CEDI) will reject electronic claims submitted with a CMN or DIF.

View DME MAC Jurisdiction B Supplier Manual, Chapter 4PDF for more information on CMN requirements.

CGS Connect® RequestPDF

Request for CGS Medical Review to review pre-claim documentation for certain claims. Visit CGS Connect®  and CGS Connect Request Completion GuidePDF for more information.

Claim Status Inquiry (CSI)

Submit a request for access to or a request to retain access to the CSI system to CGS. Visit Claim Status & Remittance Advice/Payment Information for more information.

CMS 1500 Health Insurance Claim FormExternal PDF

Access a sample of the paper claim form. Visit Paper Claims for more information.

DME Information Forms (DIF)

CMS is discontinuing the use of CMNs and DIFs for dates of service on or after January 1, 2023. For services on or after January 1, 2023, Common Electronic Data Interchange (CEDI) will reject electronic claims submitted with a CMN or DIF.

View DME MAC Jurisdiction B Supplier Manual, Chapter 4PDF for more information on DIF requirements.

Documentation Checklists

Access 30+ documentation checklists to assist with gathering required medical records and documentation for specific items.

Documentation Separator Sheets

Use the claim documentation separator sheets to label the different types of documentation without writing on or altering the records. View Claim Documentation for more information.

Electronic Funds Transfer (EFT) Authorization Form (CMS-588)External PDF

Receive payments electronically. Visit DME MAC Jurisdiction B Supplier Manual, Chapter 6PDF for more information. The mailing address is located on the Jurisdiction B Contact Information page.

Local Coverage Determinations (LCDs)

Note: This is not for appeals of individual claim denials. If you are appealing a claim denial, please see the "Appeals" sections above.

Visit Local Coverage Determinations (LCDs) for more information.

Note: This is not for appeals of individual claim denials. If you are appealing a claim denial, please see the "Appeals" sections above.

Medicare Secondary Payer (MSP) QuestionnairePDF

Supplement your beneficiary intake process by using this questionnaire to determine MSP. Visit DME MAC Jurisdiction B Supplier Manual, Chapter 11PDF for more information.

myCGS Additional Tax ID Request FormPDF

Visit myCGS Web Portal for more information. If you have not yet registered for the DME myCGS web portal, view the myCGS Registration & Account Management Guide.

Overpayment Recovery/Financial

Visit Overpayment Recovery for more information.

Prior Authorization Request CoversheetPDF

Used to submit requests to the DME MAC for items that require prior authorization as a condition of payment. Visit Prior Authorization for more information.

Provider Outreach and Education (POE) Speaker Request FormPDF

State, trade, or other industry groups and associations use this form to request a CGS POE representative to speak at their conferences or meetings.

PWK Fax/Mail/esMD Instructions and Cover SheetPDF

Used to submit documentation to accompany an electronically submitted claim. Visit the PWK Segment for more information.

Process Improvement Plan (PIP)PDF

As a component of Targeted Probe and Educate (TPE), PIP includes an outline of steps to correct each identified issue and outline goals and intervention strategies to address the issues. 

Refill Request Documentation FormPDF (Suggested Refill Request Form)

CGS created this form to help you obtain documentation to support a request for a refill. Read Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website for more information.

Reopenings

Reopenings for Minor Errors and Omissions

Signature Attestation StatementPDF

Outlines CMS signature requirements and shares an attestation statement example.

Statement of Certifying Physician for Therapeutic ShoesExternal PDF

Example statement that may be used by the certifying physician for therapeutic shoes for persons with diabetes.

Targeted Probe and Educate (TPE) Additional Documentation CoversheetPDF

Only use this coversheet at Medical Review's request for submitting additional documentation during a TPE review.

The documents offered above are in Adobe PDF format. Download a free copy of Acrobat ReaderExternal Website.

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