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Medicare Assured Forms & Reference Materials

Medicare Assured Provider Manual
Provider Manual

NIA Reference Material
NIA Reference Material

Medicare Assured Provider Forms and Reference Material
Home Infusion Drug Request Form
Hospice/Medicare Part D Prior Authorization Request Form
Medicare Part D Coverage Determination Request Form
Pharmacy NCPDP Payer Sheet
Request for Drug Coverage Form
Synagis Prescription and Prior Authorization Request Form
Discharge Form
IP Psych Form
IP Substance Abuse Authorization Request Form
Outpatient Authorization Request Form
Request for Home Health RN Visits
Request For Home Health Aide Visits
Request for Social Worker Visit
Request For Therapy Services
After Hours Services
Appointment of Representative Form
Annual Wellness Visit Tools and Reference Materials
Care for Older Adults (COA) Form
Cataract Removal Questionnaire
CMS-1500 Form
CMS UB-04 Form
Clearinghouse/Vendor Trading Partner Agreement
Cultural Competency Data Form
Electronic Funds Transfer (EFT) Authorization Agreement Form
How to Use the Provider Portal Search Tool
ICD-10 Submitter-Provider Quick Start Guide
In-Service Materials
Late Notification FAQ - Medicare
Living Will Declaration
Mass Claims Adjustment Coding Guide
Mass Claims Adjustment Tip Sheet
Maternity Outcomes Authorization Form
Medicare Outpatient Observation Attestation
Medicare Outpatient Observation Notice
Medicare Outpatient Observation Notice Instructions
Member Outreach Form
Model of Care
National Imaging Associates, Inc.(NIA) program information
NaviNet Phase 2
New Trading Partner Application
Non-Participating Provider Complaint Form
Obstetrical Needs Assessment Form (ONAF)
On Call Primary Care Practitioner Coverage Agreement
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Optum OB User Guide
Outpatient Program Exceptions Request – Please submit via Navinet.
Practice/Provider Change Request Form
Practitioner and Provider Satisfaction Survey Results
Prior Authorization Requirements (PA)
Provider Self-Audit Overpayments Form
Provider Trading Partner Agreement
Refund Form
Submit Authorizations Electronically Training Guide
TCM Tools and Reference Material
Transitional Care Management
Waiver of Liability Statement Form

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