LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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Forms & Checklists

Use the forms and coversheets below for submitting information to the JC DME MAC. The checklists, beneficiary questionnaires, and samples of attestation statements and notifications are useful in gathering information to document certain DMEPOS requirements. Mailing addresses and fax numbers are listed on the JC Contact Information page and/or the form/coversheet.

Visit CMS FormsExternal Website for a complete list of CMS forms.

Note: Visit the Guides & Charts page for charts, job aids, and guides to help suppliers navigate Medicare claims, documentation requirements, and appeals.

Title

Description/Additional Information

Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131External Website (English and Spanish forms are located under Downloads)

Used in situations where Medicare payment is expected to be denied. Keep a copy of the ABN on file to make available upon request. Visit Advance Beneficiary Notices (ABNs) for more information.

Advanced Determination of Medicare Coverage (ADMC) RequestPDF

Submit an ADMC request to the DME MAC for prior approval of customized wheelchairs before delivery. This is a voluntary program. Visit Advanced Determination of Medicare Coverage (ADMC) for more information.

Beneficiary Intake QuestionnairePDF (Suggested Intake Form)

Build a strong intake process by gathering information from the beneficiary about same or similar equipment, basic eligibility information, other insurance, and ordering practitioner information.

Capped Rental and Inexpensive or Routinely Purchased Items Notification (Purchase Option Letter)External PDF

An example of a purchase option letter to notify the beneficiary of the option to purchase or rent capped rental items. Visit DME MAC Jurisdiction C Supplier Manual, Chapter 5PDF for more information.

Certificate of Medical Necessity (CMNs)

View DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF for more information on CMN requirements.

CGS Connect™ RequestPDF

Request for CGS Medical Review to review pre-claim documentation for certain claims. Visit CGS Connect™  and CGS Connect Request Completion GuidePDF for more information.

Claim Documentation Separator Sheets

Use the claim documentation separator sheets to label the different types of documentation without writing on or altering the records. View Claim Documentationfor more information.

Claim Statue Inquiry (CSI)

Submit a request for access to or a request to retain access to the CSI system to CGS. Visit Claim Status & Remittance Advice/Payment Information for more information.

CMS 1500 Health Insurance Claim FormExternal PDF

Access a sample of the paper claim form. Visit Paper Claims for more information.

DME Information Forms (DIF)

View DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF for more information on DIF requirements.

Documentation Checklists

Access 30+ documentation checklists to assist with gathering required medical records and documentation for specific items.

Electronic Funds Transfer (EFT) Authorization Form (CMS-588)External PDF

Receive payments electronically. Visit DME MAC Jurisdiction C Supplier Manual, Chapter 6PDF for more information. The mailing address is located on the Jurisdiction C Contact Informationpage.

Español

En esta página encuentra los documentos, formularios, guías y herramientas en español junto con una breve explicación acerca de su uso.

Local Coverage Determinations (LCDs)

Visit  Local Coverage Determinations (LCDs) for more information.

Medicare Secondary Payer (MSP) QuestionnairePDF

Supplement your beneficiary intake process by using this questionnaire to determine MSP. Visit DME MAC Jurisdiction C Supplier Manual, Chapter 11PDF for more information.

myCGS Additional Tax ID Request FormPDF

Visit myCGS Web Portal for more information. If you have not yet registered for the DME myCGS web portal, view the myCGS Registration & Account Management Guide.

Overpayment Recovery/Financial

Visit Overpayment Recovery for more information.

Prior Authorization Request CoversheetPDF

Used to submit requests to the DME MAC for items that require prior authorization as a condition of payment. Visit Prior Authorization for more information.

Provider Outreach and Education (POE) Speaker Request FormPDF

State, trade, or other industry groups and associations use this form to request a CGS POE representative to speak at their conferences or meetings.

PWK Fax/Mail/esMD Instructions and Cover SheetPDF

Used to submit documentation to accompany an electronically submitted claim. Visit the PWK Segment for more information.

Process Improvement Plan (PIP)PDF

As a component of Targeted Probe and Educate (TPE), PIP includes an outline of steps to correct each identified issue, as well as goals and interventions used to address the issues.

Reconsideration Request FormPDF 

2nd Level of Appeal – submit to Quality Independent Contractor (QIC).
Visit The 5 Levels of the Appeals Process for more information.

Redeterminations

1st Level of Appeal – submit to the DME MAC.
Visit Redetermination Request Form Completion GuidePDF for more information.

If you need to send more than one redetermination request in a single fax transmission, you can do so with the Redetermination Request Separator SheetPDF. Whether you have two, three, or more separate redetermination requests, simply insert the separator sheet in between each of the requests in your fax. When CGS receives the fax, our scanning technology will detect the separator sheet and know to separate each section of the fax automatically.

Refill Request Documentation FormPDF (Suggested Refill Request Form)

CGS created this form to help you obtain documentation to support a request for a refill. Read Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website for more information.

Reopenings

Visit Reopenings for Minor Errors and Omissions and Reopening Request Form Completion GuidePDFfor more information.

Use the Multiple Claim/Beneficiary Reopenings FormPDF with the Reopening Request FormPDF when a reopening is requested on multiple claims and/or beneficiaries for the same reason.

Signature Attestation StatementPDF

Outlines CMS signature requirements and shares an attestation statement example.

Statement of Certifying Physician for Therapeutic ShoesExternal PDF

Example statement that may be used by the certifying physician for therapeutic shoes for persons with diabetes.

The documents offered above are in Adobe PDF format. Download a free copy of Acrobat ReaderExternal Website.

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