- Redetermination Completion Guide
- Redetermination Request Checklist
Reconsideration - (Second level)
- CMS 20033 - Medicare Reconsideration Request
Administrative Law Judge (ALJ) Hearing - (Third level)
Medicare Appeals Council Review (Departmental Appeals Board (DAB)) - (Fourth level)
CMS-1500 Claim Form
This form is the prescribed form for claims prepared and submitted by physicians or suppliers. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800.
- CMS-1500 Claim Form Instructions
- CMS-1500 Claim Form Tutorial
Educational Request Forms
- DME Individual Education Request Form [PDF] - Request a one-on-one virtual visit with a DME Education Representative
- DME Provider Outreach and Education Advisory Group JD Membership Application [PDF] - Apply to be a member of the DME POEAG to assist Noridian in the creation, implementation, and review of Noridian's provider education and training strategy and efforts
- Speaker Request Form for DME Events [PDF] - Request Noridian's DME Outreach and Education team participation at your event
Enrollment Forms
- CMS 588 - Electronic Fund Transfer Authorization
- CMS 855S - Enrollment Application
Freedom of Information Act (FOIA) Form
- Freedom of Information Act (FOIA) Request [PDF]
Medicare Secondary Payer (MSP) Forms
- MSP Overpayment Refund Form [PDF] - Refund related to MSP claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form
Miscellaneous Forms
- Paperwork (PWK) Fax/Mail Coversheet [PDF]
- Review Contractor Correspondence Tracking [Excel]
- Signature Attestation Statement [PDF]
- Suggested Intake [PDF]
Comprehensive Error Rate Testing (CERT)
- Provider CERT POC [PDF]
Pre-Claim Review Forms
- Advance Determination of Medicare Coverage (ADMC) Coversheet [PDF]
- DME Prior Authorization Collaborative Education Request Form [PDF]
- Prior Authorization Request for Durable Medical Equipment Coversheet [PDF]
Refunds/Overpayments Forms
- Accelerated and Advance Payment Form [PDF]
- CAAP Debt Dispute Form [PDF]
- CMS 379 - Financial Statement of Debtor
- ERS Amortization Schedule [Excel]
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Recoupment/Offset [PDF] - When requesting immediate recoupment before automatic offset
- MSP Overpayment Refund Form [PDF] - Refund related to Medicare Secondary Payer (MSP) claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
- Non-MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
Reopening Form
- Medicare DME Reopening Request [PDF]
- Reopening Completion Guide
- Reopening Request Checklist
User Provisioning (Claim Status Inquiry Support) Form
- Medicare Claims Processing System DDE/PPTN/CSI User Request [PDF]
Form Assistance
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User License Agreement and Consent to MonitoringEnd User Agreements for Providers
Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes.
Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. If you choose not to accept the agreement, you will return to the Noridian Medicare home page.
THE LICENSES GRANTED HEREIN ARE EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THESE AGREEMENTS. BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS.
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LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT)
FOURTH EDITIONEnd User/Point and Click Agreement:
CPT codes, descriptions and other data only are copyright 2002-2020 American Medical Association (AMA). All Rights Reserved. CPT is a trademark of the AMA.
You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA Web site, https://www.ama-assn.org.
This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.
AMA Disclaimer of Warranties and Liabilities
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. The AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with Noridian Healthcare Solutions or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product.CMS Disclaimer
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. The CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third-party beneficiary to this license.
LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")
End User/Point and Click Agreement
These materials contain Current Dental Terminology, (CDT), copyright © 2020 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.
1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.
3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE ("NUBC")
Point and Click American Hospital Association Copyright Notice
Copyright © 2021, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816
Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.
To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. To license the electronic data file of UB-04 Data Specifications, contact AHA at (312) 893-6816. You may also contact AHA at ub04@healthforum.com.
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Warning: you are accessing an information system that may be a U.S. Government information system. If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. Users must adhere to CMS Information Security Policies, Standards, and Procedures. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. The use of the information system establishes user's consent to any and all monitoring and recording of their activities.
Note: The information obtained from this Noridian website application is as current as possible. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval.
This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. This system is provided for Government authorized use only. Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties. At any time, and for any lawful Government purpose, the government may monitor, record, and audit your system usage and/or intercept, search and seize any communication or data transiting or stored on this system. Therefore, you have no reasonable expectation of privacy. Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose.
