Format for Requesting Assistance From Another A/B MAC or

50.3 - Format for Requesting Assistance From Another A/B MAC or DME MAC on CWF Edits (Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) Exhibit 1 contains the required format for requesting assistance. The requesting A/B MAC or DME MAC uses that format in designing its form letter so that both its address and the assisting A/B MAC or DME MAC's address will be visible through a window envelope. The requesting A/B MAC or DME MAC completes all data elements. Note that the form is designed so that a standard number 10 - 4 1/8 by 9 1/2 inch window envelope can be used for your request. The assisting A/B MAC or DME MAC may refold the form and use the same size window envelope in its reply. The requesting A/B MAC or DME MAC enters its address in the bottom address space, and uses the following in the top address space: A/B Medicare Administrative Contractor or DME MAC (as applicable) or Name of Contractor PO Box or Street Address City, State, ZIP Code Exhibit 1 - Request for Assistance Date___________ ┌ ┐ To: Request: ___ First ___ Follow up ___ RO copy └ ┘ Date of First Request _______________ (If Follow up) We request assistance in resolving CWF reject, edit code_______________________ enter code # The following action is requested: IDENTIFYING INFORMATION ______________________________ ___________________________________ Medicare beneficiary identifier Beneficiary Name ______________________________ ______________________________ Your ICN Your Provider ______________________________ ______________________________ From Date Through Date Explanation of action taken by assisting A/B MAC or DME MAC: REQUESTOR INFORMATION __________________________________ Claim # __________________________________ Dates of Service Response Date __________________________________ ____ Final Provider ____ Status __________________________________ Other Return To: Requesting Contractor Name Address Line 1 __________________________________ Address Line 2 Contact Person and Phone # Address Line 3 (if needed)