Tools & forms: Compliance / Review

Tools


Forms

Prior authorization

Form Description

     PAR coversheet for RSNAT

Use this coversheet to submit a prior authorization request (PAR) for repetitive scheduled non-emergent ambulance transports (RSNAT) before the service is provided to the beneficiary and prior to the claim being submitted for processing.

PAR coversheet for hospital OPD

Use this coversheet to submit a prior authorization request (PAR) for certain hospital outpatient department services before the service is provided to the beneficiary and prior to the claim being submitted for processing.

Expedited PAR coversheet for hospital OPD

Use this coversheet to submit an expedited prior authorization request (PAR) for certain hospital outpatient department services. 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 audit

Form Description

Provider audit master information

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.