Clerical reopenings -- submit minor corrections outside of the appeals process online using SPOT, or by calling the IVR (Interactive Voice Response).Medicare Part B PWK fax/mail/esMD coversheet 
-- Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim - required for forms received on and after April 1, 2018. Avoid processing issues: Submitting the correct form is important -- Use the correct form today to avoid processing issues.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.
COVID-19 vaccines or monoclonal antibody infusion: Roster sheet -- This roster may be used to capture patient information when creating an COVID-19 vaccine or monoclonal antibody infusion roster.COVID-19 vaccine:CMS-1500 (02/12) example -- Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for the COVID-19 vaccine on and after December 11, 2020.COVID-19 monoclonal antibody infusion: CMS-1500 (02/12) example -- Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for COVID-19 monoclonal antibody infusions on and after November 10, 2020.Influenza virus vaccine roster -- here is a roster to use to capture patient information when creating an influenza virus vaccine roster.Influenza virus vaccine - sample CMS 1500 (02/12) -- use this example to learn how to complete the CMS-1500 (2/12) form when roster billing claims for influenza.Pneumococcal pneumonia virus vaccine roster -- here is a roster to use to capture patient information when creating a pneumococcal pneumonia virus vaccine roster.Pneumococcal pneumonia virus vaccine - sample CMS-1500 (02/12) -- use this example of how to complete the CMS-1500 (02/12) form when roster billing claims for pneumococcal pneumonia virus vaccine. Extended repayment schedule for corporation or group form -- this document is required to consider an extended repayment schedule request for a corporation or group. Extended repayment schedule for sole proprietor form -- this document is required for sole proprietors who wish to request an extended repayment schedule.Return of monies voluntary refund form -- this form is required to provide claim specific information for provider-advised overpayments. Request for immediate offset form -- use this interactive form when requesting immediate offset of overpayments. CAAP debt dispute request -- use this form for COVID-19 Accelerated and Advance Payment (CAAP) Debt Dispute overpayments.Prior authorization request (PAR) for repetitive scheduled non-emergent ambulance transports (RSNAT) Medicare Part B fax/mail coversheet -- The supplier must submit the PAR before the service is provided to the beneficiary and before the claim is submitted for processing Learn more about the overall PAR RSNAT process.PAR hospital outpatient procedures Medicare Part A fax/mail coversheet -- The hospital outpatient department (OPD), or provider on behalf of the hospital OPD, must submit the PAR for certain hosptial OPD services. Learn more about the overall PAR OPD process.PAR hospital OPD Medicare Part A expedited fax/mail coversheet Note: This form should only be submitted if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. 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.
