Corporate
CGS Administrators, 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

 

Redetermination Request (Level 1) PDF

Reconsideration Request (Level 2) PDF

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

CMN CMS-854 - Section C Continuation FormPDF

Condition of Payment Prior Authorization Request CoversheetPDF

Process Improvement PlanPDF

Prior Authorization Request Cover SheetPDF

DME Information Form CMS-10125 - External Infusion PumpPDF DME information Form CMS-10126 – Enteral and Parenteral NutritionPDF

Oxygen CMNPDF

Seatlift CMNPDF

Pneumatic Compression DevicesPDF

Osteogenesis StimulatorsPDF

Refill Request FormPDF Transcutaneous Electrical Nerve StimulatorsPDF 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 DrugsPDF

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

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

Interactive ABN ToolExternal Website

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 Recertification 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

Cures Act - Addition of the KE ModifierPDF

Purchasing Paper CMS 1500 Claim FormsExternal Website

Physician Documentation Request LetterPDF

PWK Fax/Mail/esMD Cover SheetPDF 

Reopening Request FormPDF

Reopening Request Form: Cures Adjustments - KE Modifier OnlyPDF

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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