Official Federal Forms > Centers For Medicare And Medicaid Services
Part A Reconsideration Input Record CMS-352 - Official Federal Forms
| Part A Reconsideration Input Record Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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PART A RECONSIDERA TION INPUT RECORD RECORD IDENTIFIER H.I. CLAIM NUMBER ADMISSION/HHA DATE (MMDDYYYY) A SURNAME GIVEN NAME RECON. FILED (MMDDYYYY) PR OVIDER NUMBER REQUESTED BY ORIG. AMT. APPEALED BLANK - BENEFICIARY 1. ATTORNEY 3. PROVIDER 2. RELATIVE 4. OTHER RESIDENT INTER. RESIDENT INTER. RECEIPT DATE- (MMDDYYYY) RECON. INTER. RECON. INTER. RECEIPT DATE - (MMDDYYYY) AMT. AFTER RECON. RECON. COMPLETED DATE - (MMDDYYYY) RECON. DECISION AMT. AFTER RECON. CODE 1. AFF. 3. P/R 5. DIS 1. UNDER $100 4. NONE 2. $100 TO $1000 5. UNKNOWN 2. REV. 4. WD 3. OVER $1000 GOOD CAUSE TRANSFER/ACTION WAIVER OF LIABILITY ISSUE 1. YES 1. YES CONGRESSIONAL INTEREST 1. YES American LegalNet, Inc. www.USCourtForms.comForm CMS-352 (6-86)
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