Form Cms-1980 - Carrier Or Intermediary Request For Sso Assistance
ADVERTISEMENT
1
2
3DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. DATE
CARRIER OR INTERMEDIARY USE
CARRIER OR INTERMEDIARY REQUEST
FOR SSO ASSISTANCE
2a. BENEFICIARY NAME
b. SEX
c. HEALTH INSURANCE CLAIM NUMBER
d. PHONE NUMBER
M
F
3. ADDRESS OF BENEFICIARY
4a. NAME AND ADDRESS OF PERSON TO BE
b. PHONE NUMBER
CONTACTED IF OTHER THAN BENEFICIARY
c. RELATIONSHIP TO
BENEFICIARY
5. TO (Assisting SSO Office) (Send through parallel SSO unless direct contact permitted.)
6. FROM
PART I – CARRIER OR INTERMEDIARY REQUEST
7. CLAIMS MATERIAL ATTACHED
YES
NO
9. INFORMATION REQUEST (Please verify)
8. DEVELOPMENT REQUEST (Please obtain)
a.
HI CLAIM NUMBER
a.
COMPLETION OF (Form CMS-1490) (CMS-
b.
BENEFICIARY NAME
ITEM(S):
b.
UNDERPAYMENT DEVELOPMENT (Contact is shown in 6 above
above if known.)
MEDICAL EXPENSES PAID
YES
NO
c.
ADDRESS OF BENEFICIARY
OBTAIN:
c.
EOMB UNDELIVERABLE. NO BETTER ADDRESS AVAILABLE.
d.
CODE
REJECT. SEE SPECIFIC INSTRUCTIONS
d.
OTHER
FOR DO HANDLING OF THIS TYPE OF REJECT. IF
NECESSARY, TAKE STEPS TO ENTER OR CORRECT
INFORMATION ON HI TAPE.
e.
BENEFICIARY NEEDS SPECIAL ASSISTANCE. CONTACT IS
SHOWN IN 6 ABOVE
f.
OTHER
10.
FOLLOW-UP TO ORIGINAL REQUEST
11. REMARKS
PART II – SSO REPLY (Return through parallel SSO unless direct return permitted.)
12. REPLY (Continue on reverse if necessary) OR
IS ATTACHED
Form CMS-1980 (3-78)
1. Servicing SSO
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical