CorporateBusiness Services
CGS Associates, LLC

Forms

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 Request

Redetermination Request

Separator Sheet

Redetermination Checklist

Redetermination Completion Guide

Separator Sheet Instructions
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Medical Review

 

Forms

 

Checklists

 

Guides/ Instructions

 

ADMC Request

CGS Connect Request

Condition of Payment Prior
Authorization Request Coversheet


Corrective Action Plan

Prior Authorization Request
Cover Sheet


DME Information Form CMS-10125
-  External Infusion Pump

DME information Form CMS-10126
– Enteral and Parenteral Nutrition

Oxygen CMN

Seatlift CMN

Pneumatic Compression Devices

Osteogenesis Stimulators

Refill Request Form

Transcutaneous Electrical
Nerve Stimulators


Statement of Certifying Physician
for Therapeutic Shoes – Attached to LCD

Advanced Beneficiary Notice of
Noncoverage (ABN)

New Supplier Checklist

Documentation Checklists

Enteral Nutrition


Glucose Monitors and Supplies

Hospital Beds and Accessories

Immunosuppressive Drugs

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

Large Volume Nebulizers and Inhalation Drugs

Lower Limb Prostheses

Manual Wheelchairs

Nebulizers and Inhalation Drugs:
Iloprost and Treprostinil

Oxygen and Oxygen Equipment
— Beneficiaries Meeting Group I Criteria


Oxygen and Oxygen Equipment
— Beneficiaries Meeting Group II Criteria


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


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


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


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


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)


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


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

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


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


Small Volume Nebulizers and Inhalation Drugs
Support Surfaces: Group 2 Pressure
Reducing Support Surface

Support Surfaces: Group 3 Pressure
Reducing Support Surface


Therapeutic Shoes for
Persons with Diabetes


Urological Supplies: Intermittent Catheters

CGS Connect Request Form
Instructions

CMS Signature Requirements

Separator Sheet Instructions

Medicare Advance Beneficiary
Notices MLN Publication

Power Mobility Device (PMD)
Demonstration Operational Guide

Prior Authorization Process for
Certain Durable Medical Equipment,

Prosthetics, Orthotics, and Supplies
(DMEPOS) Items — or Condition of
Payment Prior Authorization

Operational Guide

 

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myCGS and CSI

 

Forms

 

Checklists

 

Guides/ Instructions

 

CSI User ID Access Request Form

CSI User ID Recertification Form

myCGS Additional Tax ID Request Form

myCGS Approver Designation Form

 

myCGS Reference Guide

myCGS Registration Guide

myCGS User Manual

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Medicare Second Payer

 

Forms

 

Checklists

 

Guides/ Instructions

 

Medicare Secondary Payer
(MSP) Questionnaire

Other Insurer Intake Tool

Medicare Secondary Payer Fact Sheet

Medicare Secondary Payer Job Aid

CMS Guidelines and Resources
for Medicare Secondary Payer
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Claims/Reopenings

 

Forms

 

Checklists

 

Guides/ Instructions

 

CMS 1500

Purchasing Paper CMS 1500
Claim Forms


Physician Documentation
Request Letter


PWK Fax/Mail Cover Sheet 

Reopening Request Form

Suggested Intake Form

Reopenings Checklist

CMS 1500 Claim Form - Interactive

CMS 1500 Fact Sheet

Reopening Request Form Completion Guide
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Electronic Data Interchange (EDI)

 

Forms

 

Checklists

 

Guides/ Instructions

 

CEDI Enrollment Forms

Electronic Funds Transfer (EFT)
Authorization Agreement

 

CEDI Enrollment Information

CEDI Software and Documentation

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Overpayment Recovery/Financial

 

Forms

 

Checklists

 

Guides/ Instructions

 

Offset Request Form

Voluntary Overpayment Refund

Overpayment Recovery Request Form

Accelerated/Advance Payment Request Form

 

 

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Miscellaneous

 

Forms

 

Checklists

 

Guides/ Instructions

 

Publication Order Form

 

 

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Español

 

Forma

 

Checklists

 

Guía/ Instrucciones

 

Requisitos de Firma de CMS

CGS Plan de Acción Correctivo

Medicare Como Pagador Secundario (MSP) Cuestionario

Solicitud de Resurtido Formato Sugerido

Formulario Inicial

 

Guía Para Completar el Formato
de Solicitud de ADMC

Guía Para Completar el
Formulario de Solicitud

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

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

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

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

Instrucciones para usar la Hoja de
Separación de Faxes

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

Tenga en Cuenta al Enviar un Fax a la
Jurisdiccion C

Uso Del Segmento PWK

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

 

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