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3rd level: Forms pertaining to a level 3 appeal -- a request for a hearing by an Administrative Law Judge
Medicare Part A PWK fax/mail coversheet -- Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim.
Direct Data Entry (DDE)
EDI forms -- find the EDI forms you need to begin electronic submissions of claims as well as an electronic data request form to apply for or revise existing information pertaining to the Electronic Remittance Advice (ERA) and/or Electronic Claim Status (ECS) transactions.
Extended repayment schedule form -- this document is required to consider an extended repayment schedule request.
Overpayment reporting -- use this interactive form when reporting overpayments.
Request for immediate offset -- use this interactive form when requesting immediate offset of overpayments.
PARD forms -- find the forms you need to submit interim rate and periodic interim payment (PIP) requests as well as statistical and reimbursement report fax sheets.
Provider Enrollment forms -- Learn which forms meet your enrollment needs and how to submit them. Find links to required enrollment applications (CMS-855), Participating physician or supplier agreement (CMS-460), and Electronic file transfer (EFT) applications (CMS-588).
CMS’ Beneficiary Notices Initiative (BNI) -- links to commonly-used beneficiary notices such as ABNs, FFS and HINNs.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.