PDF-DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID

1 PATIENT146S REQUEST FOR MEDICAL PAYMENTIMPORTANT PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTO. State based Marketplaces SBMs are encourage to adopt similar special enrollment period The document also contains information about two hardship exemptions available for eligible consumers in FFM and SBM states A Backgrou nd 45 CFR 155420d9 specifi Beneficiarys name 2 Medicare number 3 Item or service you wish to appeal 4 Date the service or item was received 5 Date of the initial determination notice please include a copy of the notice with this request If you received your initial determ What requirements must agents and brokers fulfill if they have previously completed registration for the Federally facilitated Marketplace FFM To continue p articipation in the FFM for the individual market for the 2 01 5 plan year and future plan Beneficiarys name 2 Medicare number 3 Item or service you wish to appeal 4 Date the service or item was received 5 Date of the initial determination notice please include a copy of the notice with this request If you received your initial determ 0938 1230 APPLICATION FOR ENROLLMENT IN MEDICARE PART B MEDICAL INSURANCE WHO CAN USE THIS APPLICATION People with Medicare who have Part A but not Part B NOTE If you do not have Part A do not complete this form Contact Social Security if you want t & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2 - 26 - 12 Baltimore, Maryland 21244 - 1850 Center for Medicaid, CHIP and Survey & Certification SHO # 10 Centers for Medicare & Medicaid Services Medicare Enrollment Guidelines for Ordering/Referring Providers PROVIDER–SUPPLIER ENROLLMENT FACT SHEET SERIES 2 The information in this publication app for Medicaid & Medicare Services (CMS. )/Ho-Chunk Nation:. Outreach and Education Activities . 1. CMS. (Centers for Medicare & Medicaid Services). Department of Health and Human Services (DHHS) . Centers for Medicare & Medicaid Services Improving Quality of Care for Medicare Patients: Accountable Care OrganizationsICN 907407 March 2016 .......................................................... & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2 - 26 - 12 Baltimore, Maryland 21244 - 1850 Center for Medicaid, CHIP, and Survey & Certification SMDL# WHERE IT CAME FROM Investment Other Third Party Payers and Programs 1 , 8% Government Public Activities , 3% Out of Pocket 2 , 10% Health Insurance, 75% Medicare , 21% Private Health Insura A publication of the Centers for Medicare Medicaid ServicesOffice of Information Products Data AnalyticsMedicare-Medicaid Eligible Beneficiaries and Potentially Avoidable HospitalizationsMisha Segal Exceptions included services provided under the Maternal and Child Health Services Block Grant program under x0000x0000 x/MCIxD 0 x/MCIxD 0 Under this guidance Medicaid reimbursement is available fo There are no Medicare credit balances to report for this quarter. (No Detail Page(s) attached) Telephone Number INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT— DEPA