Administration Simplification Compliance Act Waiver Request Forms
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All states
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National Government
Services, Inc.
Attn: ASCA
P.O. Box 7073
Indianapolis, IN 46250‐7073
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Appeals (i.e., review requests)
|
CA/01101, MI/452 and
450, VA/453, WI/450, WV/453
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National Government
Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149 |
Appeals (i.e., review requests)
|
ME/180, MA/181,
NH/270, NY/13201
|
National Government
Services, Inc.
P.O. Box 4711
Syracuse, NY 13221-4711 |
Appeals (i.e., review requests)
|
OH/332
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National Government
Services, Inc.
P.O. Box 7141
Indianapolis, IN 46207-7141 |
Appeals (i.e.,
review requests)
|
IL/131, IN/130,
KY/160
|
National Government
Services, Inc.
P.O. Box 7138
Indianapolis, IN 46207-7138 |
Audit & Reimbursement (i.e., cost reports and PRRB appeals)
|
ME/180
|
National Government
Services, Inc.
P.O. Box 4846
Syracuse, NY 13221-4846 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
CA/454
|
National Government
Services, Inc.
P.O. Box 7143
Indianapolis, IN 46207-7143 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
OH/332
|
National Government
Services, Inc.
P.O. Box 7141
Indianapolis, IN 46207-7141 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
IL/131
|
National Government
Services, Inc.
P.O. Box 7138
Indianapolis, IN 46207-7138 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
IN/130
|
National Government
Services, Inc.
P.O. Box 7191
Indianapolis, IN 46207-7191 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
WI/450
|
National Government
Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
KY/160
|
National Government
Services, Inc.
P.O. Box 7155
Indianapolis, IN 46207-7155 |
Audit &
Reimbursement (i.e., cost reports and PRRB appeals)
|
NY/13201
|
National Government
Services, Inc.
P.O. Box 4846
Syracuse, NY 13221-4846 |
Claims (i.e., UB-04
forms)
|
CA/01101, MI/450,
WI/450
|
National Government
Services, Inc.
P.O. Box 7150
Indianapolis, IN 46207-7150 |
Claims (i.e., UB-04
forms)
|
ME/180, MA/181,
NH/270, NY/13201
|
National Government
Services, Inc.
P.O. Box 4723
Syracuse, NY 13221-4723 |
Claims (i.e., UB-04
forms)
|
OH/332
|
National Government
Services, Inc.
P.O. Box 7141
Indianapolis, IN 46207-7141 |
Claims (i.e., UB-04
forms)
|
IN/130
|
National Government
Services, Inc.
P.O. Box 7064
Indianapolis, IN 46207-7064 |
Claims (i.e., UB-04
forms)
|
IL/131
|
National Government
Services, Inc.
P.O. Box 7138
Indianapolis, IN 46207-7138 |
Claims (i.e., UB-04
forms)
|
KY/160, VA/453,
WV/453
|
National Government
Services, Inc.
P.O. Box 7181
Indianapolis, IN 46207-7181 |
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Congressional
Correspondence
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All states
|
National Government
Services, Inc.
P.O. Box 50465
Indianapolis, IN 46250-0465
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Electronic Data
Interchange (EDI) Customer Support (i.e., electronic billing forms and
inquiries)
|
CA/454, MI/450 and
452, VA/453, WI/450, WV/453
|
National Government
Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149 |
EDI Customer Support
(i.e., electronic billing forms and inquiries)
|
ME/180, MA/181,
NH/270
|
National Government
Services, Inc.
P.O. Box 4846
Syracuse, NY 13221-4846 |
EDI Customer Support
(i.e., electronic billing forms and inquiries)
|
IL/131, OH/332,
IN/130, KY/160
|
National Government
Services, Inc.
P.O. Box 7165
Indianapolis, IN 46207-7165 |
EDI Customer Support
(i.e., electronic billing forms and inquiries)
|
NY
|
National Government
Services, Inc.
P.O. Box 4846
Syracuse, NY 13221-4846 |
|
Freedom of
Information Act (FOIA) Inquiries
|
All
|
National Government
Services, Inc.
P.O. Box 50454
Indianapolis, IN 46250-0454 |
Medical Review (i.e.,
documents/medical records and responses to additional development request [ADR}
letters)
|
ME/180, MA/181,
NH/270, NY/13201
|
National Government
Services, Inc.
P.O. Box 4767
Syracuse, NY 13221-4767 |
Medical Review
(i.e., documents/medical records and responses to ADR letters)
|
CA/454
|
National Government
Services, Inc.
P.O. Box 7143
Indianapolis, IN 46207-7143 |
Medical Review
(i.e., documents/medical records and responses to ADR letters)
|
OH/332, IL/131,
KY/160
|
National Government
Services, Inc.
P.O. Box 7141
Indianapolis, IN 46207-7141 |
Medical Review
(i.e., documents/medical records and responses to ADR letters)
|
WI/450, MI/450 and
452, CA–regional home health intermediary (RHHI)/454
|
National Government
Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149 |
Medical Policy
(i.e., policy/local coverage determination [LCD] reconsideration requests)
|
ME/180
|
National Government
Services, Inc.
Medical Policy Unit
P.O. Box 4767
Syracuse, NY 13221-4767 |
Medical Policy
(i.e., policy/LCD reconsideration requests)
|
WI/450, VA/453,
CA/454
|
National Government
Services, Inc.
Medical Policy Unit
Attn: Gina Oliveri, RN
P.O. Box 7149
Indianapolis, IN 46207-7149 |
Medical Policy
(i.e., policy/LCD reconsideration requests)
|
IL/131
|
National Government
Services, Inc.
Medical Policy Unit
Attn: Richard K. Baer, M.D.
P.O. Box 7138
Indianapolis, IN 46207-7138 |
Medicare Secondary
Payer (MSP) Inquiries/Overpayment Recovery Unit (ORU) requests (other than
those sent to MSP regional carrier)
|
OH/332
|
National Government
Services, Inc.
P.O. Box 7141
Indianapolis, IN 46207-7141 |
MSP Inquiries/ORU requests (other than those sent to MSP regional carrier)
|
IN/130
|
National Government
Services, Inc.
P.O. Box 7191
Indianapolis, IN 46207-7191 |
MSP Inquiries/ORU requests* (other than those sent to MSP regional carrier)
|
WI/450
|
National Government
Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149 |
|
ORU Correspondence
|
NY/13201
|
National Government
Services, Inc.
P.O. Box 4811
Syracuse, NY 13221-4811 |
Provider Enrollment
(i.e., CMS-855 and electronic funds transfer [EFT]
forms)
|
CA/454
|
National Government
Services, Inc.
P.O. Box 7143
Indianapolis, IN 46207-7143 |
Provider Enrollment
(i.e., CMS-855 and EFT forms)
|
IL/131, IN/130
|
National Government
Services, Inc.
P.O. Box 7078
Indianapolis, IN 46207-7078 |
Provider Enrollment
(i.e., CMS-855 and EFT forms)
|
ME/180, MA/181,
NH/270, NY/13201
|
National Government
Services, Inc.
P.O. Box 4792
Syracuse, NY 13221-4792 |
Provider Enrollment
(i.e., CMS-855 and EFT forms)
|
OH/332, KY/160
|
National Government
Services, Inc.
P.O. Box 7141
Indianapolis, IN 46207-7141 |
Provider Enrollment
(i.e., CMS-855 and EFT forms)
|
WI/450
|
National Government
Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149 |
Provider Outreach & Education (seminar payments and publication orders)
|
All states
|
National Government
Services, Inc.
P.O. Box 7191
Indianapolis, IN 46207-7191 |
|
Provider Written General Inquiries
|
All states
|
National Government
Services, Inc.
P.O. Box 7191
Indianapolis, IN 46207-7191 |