Claim Documentation Divider Sheets
CGS has created the Divider Sheets Tool to assist you in submitting the different types of documentation needed to support your claim. Simply select the type of documentation you are submitting from our list of items below. Then print the pre-designed divider sheet and place it in front of the document(s) that will be submitted for review.
As a reminder: Medical records and documents should never be altered by hi-lighting, circling or otherwise marking to bring attention to information on the record. It is not necessary to use an additional cover sheet or number the documents. Sending more than what is needed could slow down the review process and delay processing of your claim.
- Advance Beneficiary Notice (ABN)
- Certificate of Medical Necessity (CMN)/DME Information Form (DIF)
- Certifying Physician Statement
- Face-to-face Medical Record of Physical Examination
- Foot Examination
- Home Assessment
- Medical Record that Documents Patient's Condition
- Medical Records: Documentation of Continued Need
- Medical Records: Documentation of Continued Use
- Medical Records: Laboratory/Test Results
- Physician Signature Attestation
- Proof of Delivery
- Refill Request
- Repairs/Replacement Information
- Sleep Physician Credentials
- Standard Written Order
- Supplier Attestation Statement
- Written Order Prior to Delivery
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