Guide to Medicare Forms

Many Medicare transactions rely on forms. Knowing which form to submit is key. The following chart which identifies the forms that are available and the purpose of each. Tip: you can complete many of these forms electronically, then print and submit with any supporting documentation that applies.

Use this shortcut for all Palmetto GBA forms:

Form
Purpose
CMS-855 Applications (various forms on the CMS website):
 
Related forms:
  • EFT Registration Form
  • Participating Physician or Supplier Agreement
  • Enroll providers of service in the Medicare program
  • Reassign individual provider benefits to a group
  • Change addresses or other credentialing information
 
More information:
  • Save time by completing the form online at https://pecos.cms.hhs.gov (print and sign the certification page and submit any required supporting documentation within seven days)
  • Which form to submit? Check out the Palmetto GBA Provider Application Finder for assistance.
Medicare Participating Physician or Supplier Agreement (Par Agreement)
Elect to become a "participating provider" in Medicare.
 
More information:
Find out details about what it means to be participating vs. non-participating. There are important differences in reimbursement and what you may charge Medicare patients. From the home page for your state, select Browse by Topic > Provider Enrollment > General: Participation Agreement Forms and Instructions.
Electronic Funds Transfer (EFT) Registration Form
Enroll to receive your Medicare payments via direct deposit into your designated bank account (submit with your CMS-855 application).
EDI Application Online Request Form
Enroll for electronic claim submission privileges.
EDI Fax Cover Sheet
Cover sheet for supporting documentation for electronic claims. Transmit fax one to two days prior to or same day as claim submission.
CMS Advance Beneficiary Notice of Noncoverage (ABN)
Notify a Medicare patient that a service being rendered may not be paid by Medicare.
 
More information:
Overpayment Refund Form
Notify Palmetto GBA when you identify an overpayment from Medicare.
Extended Repayment Plan (ERP) Form
Request an extended repayment plan when an overpayment is assessed and you cannot repay the amount within 30 days of receipt of the first demand letter.
Redetermination/Reopening Request Form
Appeal an initial claim determination (usually a denial) or to request a reopening of a claim (usually a denial that is based on a clerical error or other minor error).
 
More information:
  • If you are unsure whether to request a redetermination or a reopening, request a redetermination, as there are specific time limits for submitting redetermination requests
  • You must request a redetermination within 120 days of the date of the initial claim determination
  • Please note: claims that are "returned as unprocessable" (remark code MA130) have no appeal rights and should not be sent for redetermination. These claims must be corrected and resubmitted as new claims.
Reconsideration Request Form
Request the second level of appeal. 
 
More information:
  • A reconsideration is "an appeal of an appeal." This form may be used only after a redetermination (first level of appeal) has been completed and you wish to appeal the contractor’s redetermination decision to the next level. The reconsideration is the second level of appeal.
  • Do not submit these forms to Palmetto GBA. Access the Palmetto GBA Forms Web page for your state to download the form, and submit to the address listed on the form.
Written Inquiry Form
Submit a question to Palmetto GBA.
 
More information:
  • The form makes it easy for you to submit all required authentication information (NPI, PTAN and TIN) and a clear description of your question
  • It also includes other resources that may help you obtain a quicker response
MSP Explanation Form
Provide supporting documentation for paper MSP claims. This form is particularly useful for situations in which the primary insurers' explanation of benefits (EOB) is very general regarding the reason the service was denied or only partially paid.
 

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