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Why Performant?
Solutions
Audit Advantage
Data Mining Advantage
Eligibility Advantage
Customer Care
Resources
Case Studies & Fact Sheets
Acronyms
CMS RAC
Secure Provider Portal
CMS RAC Resources
Update Provider Contact Information
Contact
About Us
Overview
Leadership
Locations
Newsroom
News Releases
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Overview
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Stock Information
Financials
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Forms and Sample Documents
Why Performant?
Solutions
Audit Advantage
Inpatient & Facility Audits
Outpatient Audits
High Risk & Specialty Audits
Data Mining Advantage
Eligibility Advantage
Customer Care
Resources
Case Studies & Fact Sheets
Acronyms
CMS RAC
Secure Provider Portal
CMS RAC Resources
Provider Resources
Provider Portal
Region 1
Region 2
Region 5
Update Provider Contact Information
Contact
About Us
Overview
Leadership
Locations
Newsroom
News Releases
Investors
Overview
News
Events & Presentations
Stock Information
Stock Quote & Chart
Historical Stock Quote
Analyst Coverage
Financials
Quarterly Results
Annual Reports
SEC Filings
Governance
Governance Documents
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Committee Composition
Contact the Board
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Investor Emails Alerts
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Search query
Home
>
CMS RAC
>
CMS RAC Resources
>
Forms and Sample Documents
Why Performant?
Solutions
Audit Advantage
Inpatient & Facility Audits
Outpatient Audits
High Risk & Specialty Audits
Data Mining Advantage
Eligibility Advantage
Customer Care
Resources
Case Studies & Fact Sheets
Acronyms
CMS RAC
Secure Provider Portal
CMS RAC Resources
Provider Resources
Provider Portal
Region 1
Region 2
Region 5
Update Provider Contact Information
Contact
About Us
Overview
Leadership
Locations
Newsroom
News Releases
Investors
Overview
News
Events & Presentations
Stock Information
Stock Quote & Chart
Historical Stock Quote
Analyst Coverage
Financials
Quarterly Results
Annual Reports
SEC Filings
Governance
Governance Documents
Board of Directors
Committee Composition
Contact the Board
Resources
Investor FAQs
Investor Emails Alerts
Investor Contacts
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Home
>
CMS RAC
>
CMS RAC Resources
>
Forms and Sample Documents
This page contains samples of many of the documents that a provider might need or expect to receive from the RAC.
Please click on any of the links below to see the sample document.
Download item year list
Download
Description
Discussion Request Form
(opens in new window)
249 KB
ADR Submission Instructions
(opens in new window)
85 KB
Welcome Letter Template
(opens in new window)
356 KB
Additional Documentation Request (ADR) Letter
(opens in new window)
347 KB
Review Results Letter - DRGRRL
(opens in new window)
1.23 MB
Review Results Letter - GenericRRL
(opens in new window)
1.16 MB
Review Results Letter-No Finding Letter
(opens in new window)
213 KB
Review Results Letter-Technical Denial
(opens in new window)
218 KB
Automated Review Initial Findings Template
(opens in new window)
585 KB
Complex Review Underpayment Template
(opens in new window)
200 KB
Automated Review Underpayment Findings Template
(opens in new window)
278 KB
Original Decision Upheld Template
(opens in new window)
197 KB
Original Decision Overturned template
(opens in new window)
176 KB
Discussion Closed Appeal Request template
(opens in new window)
195 KB
Discussion Closed Days Exceeded template
(opens in new window)
216 KB
Rescind Request Template
(opens in new window)
240 KB
Medical Records Received Too Late Template
(opens in new window)
190 KB
Understanding Remittance Advice (CMS Website)
(opens in new window)
Region 1 Provider MACS
(opens in new window)
142 KB
Region 2 Provider MACS
(opens in new window)
229 KB
Region 5 DME HHH MACS
(opens in new window)
149 KB