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

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 1 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-Based) StudyPDF


Power Mobility:  Group I PWCs (K0813-K0816)
and Group II PWCs (K0820-K0829)PDF


Power Mobility:  Group 2 Single Power
Options PWCs (K0835-K0840) & Group 2PDF


Multiple Power Options 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 And 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) 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

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 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

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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