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The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Many CMS program related forms are available in Portable Document Format (pdf).
Correspondence Cover Sheet Beneficiary Name: Medicare ID: Date of Incident: Case Identification Number: Insurer Claim Number: This cover sheet is for your use when mailing or faxing in correspondence to the Benefits Coordination & Recovery Center (BCRC). Please retain a COPY of this cover sheet for any future correspondence.
Complete all fields and fax to 877-439-5479 or mail the form to the applicable address. Complete ONE (1) Medicare Fax, Mail or Electronic Submission of Medical Documentation (esMD) Cover Sheet for each electronic claim for which documentation is being submitted. This form should not be submitted prior to filing the claim. ACN:
Medicare Part A Fax/Mail Cover Sheet. Complete all fields; attach supporting medical documentation and fax to . 877- 439-5479. or mail to the applicable address/number provided at the bottom of the page. Complete . ONE (1) Medicare Fax/ Mail Cover Sheet for each prior authorization request for which documentation is being submitted. Beneficiary ...
Complete all fields then submit this form via the Electronic Submission of Medical Documentation (esMD) system or by fax/mail to the applicable address or number provided at the bottom of the page. Complete ONE (1) Medicare Fax/Mail/esMD Cover Sheet for each electronic claim for which documentation is being submitted.
When submitting a paper attachment via a Fax, the Claims Processing PWK Fax Cover Sheet (PDF, 343 KB) must be completed. This form can be located under the Claims section of the Forms application on the Palmetto GBA website. Send all relevant PWK documentation for the claim at the same time Fax number and address is listed on the cover sheet
Complete all felds and fax or mail the form to the applicable address/number provided at the bottom of the page. Complete ONE (1) Medicare Fax/Mail/esMD Cover Sheet for each electronic claim for which documentation is being submitted. This form should not be submitted prior to fling the claim.
Medicare Part B Fax/Mail Cover Sheet This form should not be used to fax CGS request for additional documentation. Please continue to attach documentation to the ADS letter and mail to CGS. Complete all fields and fax the form to the applicable address/number provided at the bottom of the page.
Use this form to fax documentation to allow for submission of supporting documentation with an initial claim. If you are under a Targeted Probe and Educate (TPE) review, please wait for receipt of the ADR letter before sending in documentation. Tags : Claims Forms,J5B,Forms,Documentation Attached File J5B PWK Fax-Mail Cover Sheet.pdf | 83 KB
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