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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.

This newsletter contains important articles regarding electronic billing.

Avoid negative impacts to your claims by providing medical records with your initial claim submission for the other codes provided in this spreadsheet. Please consult the list frequently as it may be updated quarterly.