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MEDICARE PART D MEDICATION THERAPY MANAGEMENT PROGRAM STANDARDIZED FORMAT FORM CMS10396 (07×14)Last updated: July 15, 2014Instructions for Implementing the Standardized Forgettable of Contents Section

How to fill out form cms-10396 0714

How to fill out form cms-10396 0714?

1. Start by gathering all the necessary information. Form CMS-10396 0714 is used to request an Independent Informal Dispute Resolution (IIDR) for healthcare facilities that are certified to participate in Medicare and/or Medicaid programs. Make sure you have all the relevant details about the facility and the issue you want to dispute.
2. Begin filling out the form by providing your facility's information. This includes the facility name, address, CMS Certification Number (CCN), and the specific Program Certification Number (PCN) if applicable. Double-check the accuracy of these details to ensure that your form is processed correctly.
3. Indicate whether you are an Authorized Representative or an Authorized Representative Designee and provide the required contact information. This allows the CMS to communicate with you regarding the IIDR process.
4. In the "Nature of Appeal" section, provide a detailed explanation of the issue you are disputing. Clearly state the specific reason for your appeal and provide any supporting documentation, if necessary. It is important to be concise yet comprehensive to ensure a clear understanding of the problem.
5. Next, specify the specific Medicare/Medicaid Condition of Participation (COP) or Medicare Code of Federal Regulations (CFR) that relates to your appeal. These references are essential for the CMS to evaluate your dispute accurately.
6. In the "Request for Informal Conference (Optional)" section, indicate whether you wish to have an informal conference during the IIDR process. This conference allows you to discuss the dispute with a CMS representative and potentially reach a resolution before the formal process begins.
7. Finally, sign and date the form, confirming that all the information provided is accurate and complete. Make sure to keep a copy of the filled-out form for your records.

Who needs form cms-10396 0714?

Healthcare facilities that are certified to participate in Medicare and/or Medicaid programs and wish to request an Independent Informal Dispute Resolution (IIDR) need to fill out form CMS-10396 0714. This form allows them to communicate their dispute and seek a resolution through the IIDR process. Whether it's a hospital, nursing home, or any other eligible healthcare facility, this form is essential for those seeking to appeal certain issues related to their certification.

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