When you submit your interim financial data to National Government Services when requesting an interim rate adjustment, please use the appropriate Interim Rate Review Documentation Request Form. These forms are designed to capture important information relevant to prospective payment system ( PPS) payments (including disproportionate share hospital [DSH]) and indirect medical education (IME). Forms are also available for hospitals reimbursed under the Tax Equity & Fiscal Responsibility Act (TEFRA), as well as, critical access hospitals (CAHs).

Select from the following links to download the appropriate Interim Rate Documentation Form, complete and return the form to the Medicare Audit & Reimbursement office servicing your facility.

• Hospital Interim Rate Documentation Form
• PIP Hospital Interim Rate Documentation Form
• CAH Interim Rate Review Documentation Request Form
• TEFRA Hospital Interim Rate Documentation Form
• Hospice PIP Documentation Form