- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) - Links to the CMNs and DIFs that are used by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs). These forms are official federal documents and as such, have a number of very specific requirements and restrictions associated with their use. These forms may not be modified in any way. They are provided here as a convenience for you.
- Form CMS-1500 (08/05) - Blank CMS-1500 forms are not distributed by Medicare contractors. In order to purchase claim forms, contact the U.S. Government Printing Office at 202-512-1800, local printing companies in your area, and/or office supply stores. Each of these vendors sells the CMS-1500 form in its various configurations. The only acceptable claim forms are those printed in Flint Red, J6983, (or exact match) ink. Photocopied claims should not be submitted to Medicare contractors.
- CMS Forms - Refer to the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov/CMSForms/ for additional federal forms, such as the Advance Beneficiary Notice (CMS-R-131) and the National Supplier Clearinghouse (NSC) Application for DMEPOS Suppliers (CMS-855S).
- DME MAC Forms - Various forms that are available to assist in your transactions with the Jurisdiction A DME MAC. Use of these forms is not mandatory, however, it will help to ensure that your claims information is handled in a timely and efficient manner. They are provided here as a convenience for you.
CMS maintains CMNs and DIFs. DME MAC Jurisdiction A maintains all other non-CMN forms available within this section.
Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs)
On October 1, 2006 CMS released a new series of CMN and DIF forms for use by all DME Suppliers. The below table contains links to the new CMNs and DIFs which are also available on the
CMS web site.
For more information about CMNs and DIFs the following Web sites:
CMS Forms
The below links lead to the Centers for Medicare & Medicaid Services (CMS) web site. These forms along with other CMS forms can be found on the CMS web site at http://www.cms.hhs.gov/CMSForms/.
DME MAC Forms
The Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC) maintains the forms listed below as a convenience for our supplier community.
- ADMC Request Form
 (20KB) - Use this cover sheet when submitting requests for Advance Determination of Medicare Coverage (ADMC).
- Fax Reopening Cover Sheet (69KB) - The Reopening fax process may be used to correct a claim clerical error or to submit documentation for a claim originally denied due to non response to a request for documentation. Please do not use the Reopening fax line for any submissions other than Reopening requests.
- Offset Request Form (47KB) - Use this form when requesting an immediate offset.
- Overpayment Refund Form (36KB) - Use this cover sheet when submitting voluntary refunds for an overpayment situation.
- In coordination with the New England Medical Equipment Dealers (NEMED) Association, NHIC, Corp. DME MAC A has developed the attached letter for use by our New England supplier community for submission to MassHealth Medicaid. MassHealth has agreed to the use of this generic letter rather than requiring each supplier to individually request this type of letter from DME MAC A. Note: This letter is to be used only for MassHealth. Any additional letters of this type would have to be coordinated through your state DMEPOS association or the office of your local Medicaid or private insurer. This letter is being provided in PDF format and can not be electronically altered. This form must first be printed in order to complete the required information for submission to MassHealth. If you have any questions relating to this specific letter, please contact either NEMED at 508-993-0700 or DME MAC A Customer Service at 866-419-9458.
2008 MassHealth Medicaid Letter (30KB)
2009 MassHealth Medicaid Letter (30KB)
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10/30/2009
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