CorporateBusiness Services
CGS Associates, LLC

Forms

The following forms are designed for DME suppliers who submit claims to CGS. All forms are in the Portable Document Format (pdf). If you do not have Adobe Reader software, you can download External Website it at no cost.

APPEALS MEDICAL
REVIEW
myCGS
AND CSI
MEDICARE
SECOND PAYER
CLAIMS/
REOPENINGS
ELECTRONIC DATA
INTERCHANGE (EDI)
OVERPAYMENT
RECOVERY /FINANCIAL
MISC.

Appeals

 

Forms

 

Checklists

 

Guides/ Instructions

 

Reconsideration RequestPDF

Redetermination RequestPDF

Separator SheetPDF

Redetermination ChecklistPDF

Redetermination Completion GuidePDF

Separator Sheet Instructions
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Medical Review

 

Forms

 

Checklists

 

Guides/ Instructions

 

ADMC RequestPDF

CGS Connect RequestPDF

Condition of Payment Prior
Authorization Request CoversheetPDF


Corrective Action PlanPDF

Prior Authorization Request
Cover SheetPDF


DME Information Form CMS-10125
-  External Infusion PumpPDF

DME information Form CMS-10126
– Enteral and Parenteral NutritionExternal PDF

Oxygen CMNExternal PDF

Seatlift CMNExternal Website

Pneumatic Compression DevicesExternal PDF

Osteogenesis StimulatorsExternal PDF

Refill Request FormPDF

Transcutaneous Electrical
Nerve StimulatorsExternal PDF


Statement of Certifying Physician
for Therapeutic Shoes – Attached to LCDExternal Website

Advanced Beneficiary Notice of
Noncoverage (ABN)External Website

New Supplier ChecklistPDF

Documentation Checklists

Enteral NutritionPDF


Glucose Monitors and SuppliesPDF

Hospital Beds and AccessoriesPDF

Immunosuppressive DrugsPDF

Nebulizers & Inhalation Drugs: Small
Volume Nebulizers (A7003, A7004,
A7005) & Related Compressor (E0570)PDF

Large Volume Nebulizers and Inhalation Drugs

Lower Limb ProsthesesPDF

Manual WheelchairsPDF

Nebulizers and Inhalation Drugs:
Iloprost and TreprostinilPDF

Oxygen and Oxygen Equipment
— Beneficiaries Meeting Group I CriteriaPDF


Oxygen and Oxygen Equipment
— Beneficiaries Meeting Group II CriteriaPDF


Positive Airway Pressure (PAP)
Devices for the Treatment of OSA
Qualifying Sleep Test: Type I
(Facility-Based) StudyPDF


Positive Airway Pressure (PAP)
Devices for the Treatment of OSA
Qualifying Sleep Test: Type II, III,
IV (Home) StudyPDF


Power Mobility: Group 1 PWCs (K0813
– K0816) & Group 2 PWCs (K0820 – K0829)PDF


Power Mobility: Group 2 Single Power
Option PWCs (K0835 – K0840)
& Group 2 Multiple Power Option
PWCs (K0841 – K0843)PDF


Power Mobility: Group 3 No Power Option
PWCs (K0848 – K0855), Group 3 Single
Power Option PWCs (K0856 – K0860),
& Group 3 Multiple Power Option PWCs
(K0861 – K0864)PDF


Power Mobility: Group 5 (Pediatric)
PWCs with Single (K0890) or Multiple
(K0891) Power Options & Push-Rim
Activated Power Assist Device (E0986)
for a Manual WheelchairPDF


Power Mobility: POVs (HCPCS Codes
K0800 - K0808 and K0812)PDF

Respiratory Assist Device – E0470 Bi-Level
Pressure Capacity Without Backup RatePDF


Respiratory Assist Device – E0471 Bi-Level
Pressure Capacity With Backup RatePDF


Small Volume Nebulizers and Inhalation DrugsPDF

Support Surfaces: Group 2 Pressure
Reducing Support SurfacePDF

Support Surfaces: Group 3 Pressure
Reducing Support SurfacePDF


Therapeutic Shoes for
Persons with DiabetesPDF


Urological Supplies: Intermittent CathetersPDF

 

CGS Connect Request Form
InstructionsPDF

CMS Signature RequirementsPDF

Separator Sheet Instructions

Medicare Advance Beneficiary
Notices MLN PublicationExternal PDF

Power Mobility Device (PMD)
Demonstration Operational GuideExternal PDF

Prior Authorization Process for
Certain Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies
(DMEPOS) Items — or Condition of
Payment Prior AuthorizationExternal PDF

Operational GuideExternal PDF

 

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myCGS and CSI

 

Forms

 

Checklists

 

Guides/ Instructions

 

CSI User ID Access Request FormPDF

CSI User ID Recertification FormPDF

myCGS Additional Tax ID Request FormPDF

myCGS Approver Designation FormPDF

 

myCGS Reference Guide>

myCGS Registration GuidePDF

myCGS User ManualPDF

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Medicare Second Payer

 

Forms

 

Checklists

 

Guides/ Instructions

 

Medicare Secondary Payer
(MSP) QuestionnairePDF

Other Insurer Intake ToolExternal PDF

Medicare Secondary Payer Fact SheetExternal PDF

Medicare Secondary Payer Job AidPDF

CMS Guidelines and Resources
for Medicare Secondary Payer
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Claims/Reopenings

 

Forms

 

Checklists

 

Guides/ Instructions

 

CMS 1500External Website

Purchasing Paper CMS 1500
Claim FormsExternal Website


Physician Documentation
Request LetterPDF


PWK Fax/Mail Cover SheetPDF 

Reopening Request FormPDF

Suggested Intake FormPDF

Reopenings ChecklistPDF

CMS 1500 Claim Form - Interactive

CMS 1500 Fact SheetExternal PDF

Reopening Request Form Completion GuidePDF
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Electronic Data Interchange (EDI)

 

Forms

 

Checklists

 

Guides/ Instructions

 

CEDI Enrollment FormsExternal Website

Electronic Funds Transfer (EFT)
Authorization AgreementExternal PDF

 

CEDI Enrollment InformationExternal Website

CEDI Software and DocumentationExternal Website

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Overpayment Recovery/Financial

 

Forms

 

Checklists

 

Guides/ Instructions

 

Offset Request FormPDF

Voluntary Overpayment RefundPDF

Overpayment Recovery Request FormPDF

Accelerated/Advance Payment Request FormPDF

 

 

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Miscellaneous

 

Forms

 

Checklists

 

Guides/ Instructions

 

Publication Order FormPDF

 

 

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Español

 

Forma

 

Checklists

 

Guía/ Instrucciones

 

Requisitos de Firma de CMSPDF

CGS Plan de Acción CorrectivoPDF

Medicare Como Pagador Secundario (MSP) CuestionarioPDF

Solicitud de Resurtido Formato SugeridoPDF

Formulario InicialPDF

 

Guía Para Completar el Formato
de Solicitud de ADMCPDF

Guía Para Completar el
Formulario de SolicitudPDF

Instrucciones Para Llenar
el Formulario CMS-10125-Bombas
de Infusion ExternaPDF

Instrucciones Para Llenar el Formulario
DIF (DMI Information Form) Para
Alimentacion Enteral y Parenteral
(CMS-10126)PDF

Guía Para Completar La Hoja
de Solicitud de Preautorizacion
Oara OMD O Prior Authorization
Request (PAR) Coversheet,
Jurisdiction C Power Mobility
DemonstrationPDF

Hoja de Cubierta Para Enviar
Documentacion Correspondiente
A PWK Medicare/Fax O CorreoPDF

Instrucciones para usar la Hoja de
Separación de Faxes

Formato do Solicitud de Una
Redeterminación: Guia para
completer el FormatoPDF

Tenga en Cuenta al Enviar un Fax a la
Jurisdiccion CPDF

Uso Del Segmento PWKPDF

Guía Para Completar el Formulario de
Devolucion Voluntaria de un
Sobrepago al DME MAC Jurisdiccion CPDF

 

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