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This updated form is for an appeal and is not to be used when requesting a claim adjustment. Fill it out online, then print and mail it to the address indicated on the form.

This form is used by Medicare Part A providers who change the default or other contact who receives their interim rate, tentative settlement, NPR & NOC-PR determinations.

View this HRSA COVID-19 attestation.

Sole proprietors who wish to request an extended repayment schedule request must complete an extended repayment schedule request form.

Use this form for all overpayments. Options must be selected; if none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the end of the form.

To consider an extended repayment schedule request for a corporation or group, the following documentation is required.

View open meeting documentation from April 28, 2022, on skin substitutes. 

Expedited prior authorization request hospital outpatient procedures Medicare Part A Fax/Mail Coversheet - Allowable if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or a…