MEDICARE Part B Jurisdiction 15 Redetermination Request Form
MEDICARE Part B Jurisdiction 15 Redetermination Request Form
Provider Information Provider Name: PTAN: Tax ID: Address: City: State: Phone Number:
NPI: Zip Code:
OHIO - (15202) KENTUCKY - (15102)
Beneficiary Information Patient Name: Medicare Number: State: Phone Number:
Requestor's Name/Provider Contact Name:
Requestor's Signature:
Overpayment Appeal:
If yes, then check:
MR PROBE
Date(s) of Service:
Denied CPT/HCPCS & Modifiers
Signature not required as of July 8, 2019!
UPIC
CERT
Initial ICN (if overpayment, use the overpayment ICN:
RAC
Other
Date of Initial Determination:
Suggested Documentation Checklist: Reasons/Rationale:
Medicare Remittance Advice Advance Beneficiary Notice
Physician's Written Order Signed Medical Documentation
CGS Attn: J15 Part B Appeals Department PO Box 20018 Nashville, TN 37202
Revised July 27, 2020. ? 2020 Copyright, CGS Administrators, LLC.
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