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Medicare Assured Forms & Reference Materials



Medicare Assured Provider Manual
Provider Manual

Medicare Assured Provider Forms and Reference Material
PHARMACY FORMS
Home Infusion Drug Request Form
       - 2015 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
HOME HEALTH AUTHORIZATION FORMS
Request for Home Health RN Visits
Request For Home Health Aide Visits
Request for Social Worker Visit
Request For Therapy Services
NIA REFERENCE MATERIAL
FAQ for NIA - Gateway Health Medicare Assured
NIA Claims Matrix – Gateway Health Medicare Assured
NIA Quick Reference Guide Ordering Provider – Gateway Health Medicare Assured
NIA Quick Reference Guide Rendering Provider – Gateway Medicare Assured
GENERAL PROVIDER FORMS & REFERENCES
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
Electronic Funds Transfer (EFT) Authorization Agreement Form
ICD-10 Submitter-Provider Quick Start Guide
In-Service Materials
Late Notification FAQ - Medicare
Living Will Declaration
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
Notice of Medicare Non-Coverage Form (PA)
Notice of Medicare Non-Coverage Form (OH)
Obstetrical Needs Assessment Form
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Opioids for Pain Physician Actions
Outpatient Program Exceptions Request – Please submit via Navinet.
Patient Question List
PCP On Call Coverage Arrangement Form
Practice Change Request Form
Practitioner and Provider Satisfaction Survey Results
Prior Authorization Requirements (PA)
Provider Trading Partner Agreement
Race and Ethnicity Data Form
Refund Form
Submit Authorizations Electronically Training Guide
TCM Tools and Reference Material
Telemedicine/Telehealth Services Provider Guide
Transitional Care Management
Voiance Interpreter Services
Waiver of Liability Statement Form

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