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

Large Volume Nebulizers and Inhalation DrugsPDF

Lower Limb ProsthesesPDF

Manual WheelchairsPDF

Nebulizers and Inhalation Drugs: Iloprost and TreprostinilPDF

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

Negative Pressure Wound Therapy PumpsPDF

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 1 Pressure Reducing Support SurfacePDF

Support Surfaces: Group 2 Pressure Reducing Support SurfacePDF

Support Surfaces: Group 3 Pressure Reducing Support SurfacePDF

Surgical DressingsPDF

Therapeutic Shoes for Persons with Diabetes PDF

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) Questionnaire PDF

Other Insurer Intake FormExternal PDF

Medicare Secondary Payer Fact SheetExternal PDF

Medicare Secondary Payer Job AidPDF

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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 FormExternal 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 Refund FormPDF

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

 

Formularios

 

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

Camas Hospitalarias y AccesoriosPDF

Equipos de Asistencia Respiratoria
(E0470)PDF

Equipos de Asistencia Respiratoria
(E0471)PDF

Equipos de Presión Positiva de la Vía
Aérea (PAP) para el Tratamiento de
la OSA Estudio de Sueño Calificado:
Estudio realizado en el Hogar (Tipo II,
III, IV y Otros)PDF

Equipos de Presión Positiva de la Vía
Aérea (PAP) para el Tratamiento de
la OSA Estudio de Sueño Calificado:
Estudio realizado en una Institución
(Tipo I)PDF

Equipos Motorizados para Movilidad:
Grupo 1 PWC (K0813 - K0816) y
Grupo 2 sin "Power Option"
(K0820 - K0829)PDF

Equipos Motorizados para Movilidad:
Grupo 2 PWC con Opcion de "Single
Power" (K0835 - K0840) y Grupo 2 con
Opcion de Multiple "Power Option"
(K0841 - K0843)PDF

Monitores para Medir la Glucosa y
SuministrosPDF

Nebulizadores y Medicamentos Inhalados:
Alto Volumen (A7007, A7107) &
Compresores Relacionados (E0565,
E0572), Combo Nebulizador con Compresor
y Calentador (E0585), Nebulizador con
Filtro (A7006) & Compresores Relacionados
(E0566, E0572)PDF

Nebulizadores y Medicamentos Inhalados:
Iloprost (Q0474) y Treprostinil (J7686),
Sistema de Administracion de Medicamentos
Ihalados de Dosis Controlada (K0730) y
Nebulizador Ultrasónico de Pequeño
Volumen (E0574)PDF

Nutrición EnteralPDF

Oxígeno y Equipo para Oxígeno - Beneficiarios
que cumplen los Criterios del Grupo IPDF

Oxígeno y Equipo para Oxígeno - Beneficiarios
que cumplen los Criterios del Grupo IIPDF

POVs: Codigos HCPCS K0800 - K0802 y K0812

Prótesis de Extremidad InferiorPDF

PWCs Grupo 3 NO "Power Option" (K0848 -
K0855), Grupo 3 con "Power Option" Unica
(K0856 - K0860) y Grupo 3 con Multiples
"Power Option" (K0861 - K0864)PDF

PWCs Grupo 5 Pediátricas, con "Power
Option" Unica (K0890) ó Multiple (K0891)
Equipo Motorizado para empujar las llantas
de una silla Manual (E0986) "Push-Rim
Activated Power Assist Device"PDF

Sillas de Ruedas ManualesPDF

Suministros UrológicosPDF

Superficies de Apoyo para Reducir la
Presión, Grupo 3PDF

Zapatos Terapéuticos para personas
con DiabetesPDF

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

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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