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.
Download Here
- Discussion Request Form
- ADR Submission Instructions
- Welcome Letter Template
- Additional Documentation Request (ADR) Letter
- Review Results Letter - DRGRRL
- Review Results Letter - GenericRRL
- Review Results Letter-No Finding Letter
- Review Results Letter-Technical Denial
- Automated Review Initial Findings Template
- Complex Review Underpayment Template
- Automated Review Underpayment Findings Template
- Original Decision Upheld Template
- Original Decision Overturned Template
- Discussion Closed Appeal Request Template
- Discussion Closed Days Exceeded Template
- Rescind Request Template
- Medical Records Received Too Late Template
- Understanding Remittance Advice (CMS Website)
- Region 1 Provider MACS
- Region 2 Provider MACS
- Region 5 DME HHH MACS
