Medicare Part B Redetermination and Clerical ...
Medicare Part B Redetermination and Clerical Error Reopening Request Form
Submit Request via Fax: 904-361-0595
PLEASE COMPLETE EACH FIELD ON THE FORM TO ENSURE ACCURATE PROCESSING
Do not complete this form for the following situations:
1. If you received a Medicare Redetermination Notice (MRN) on this claim DO NOT use this form to request further appeal. Your next level of appeal is a Reconsideration by a Qualified Independent Contractor (QIC) - Form.
2. If you received a message MA-130 on the Medicare Remittance Notice for this claim, no appeal or reopening rights are available. Please submit a NEW claim with the appropriate corrections.
If this request is due to a Prior-Authorization denial select from the drop down:
Please select one of the following jurisdictions and select YES or NO to the question below:
FVPLIR
1. Does your appeal involve the Recovery Auditor (RA) decision?
YNeos
2. Does your appeal involve a 935 overpayment decision?
YNeos
3. Does the claim you are appealing involve Medicare Secondary Payer (MSP)?
YNeos
Please select one of the choices below to identify the category which the request pertains to:
PCOrhtoihcreeordpurraectCicocdeSserb07ve0ig10ci0en0sn-i68n9g99w9ith "J" or "G" or 90000-99999 or Ambulance Service
Please fill in the information below in all UPPERCASE letters:
Provider Transaction Access No (PTAN):
NPI (10 digits):
Tax Identification Number (last 5 digits):
Provider Name:
Beneficiary First Name:
Beneficiary Last Name:
Beneficiary Medicare Number (11 characters):
Claim Number (13 digits): If alpha-numeric use Part A request form
Date(s) of service
Procedure Code(s) in Question
Requestor's Name (Printed)
Requestor's Relationship to Provider
Telephone Number and Extension
Reason for Redetermination or Clerical Error Reopening Request:
52001 (R3-23)
Print Form
Clear Form
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