Medicare Part A Redetermination and Clerical ...
Medicare Part A Redetermination and Clerical Error Reopening Request Form
Submit Request via Fax: 904-361-0593
Please select one of the following jurisdictions and check YES or NO to the questions below:
If this request is due to a Prior-Authorization denial select from the drop down:
1. Are you requesting a Clerical Reopening?
YNeos
2. Does the claim you are appealing involve Medicare Secondary Payer (MSP)?
YNeos
3. Should recoupment be stopped for a 935 overpayment?
(provide a copy of the overpayment letter)
YNeos
4. Does your appeal involve the Recovery Auditor (RA) decision?
(provide a copy of the overpayment letter)
YNeos
5. Did the claim you are appealing reject with message MA-130?
YNeos
Please fill in the information below in all UPPERCASE letters: PLEASE COMPLETE EACH FIELD ON THE FORM TO ENSURE ACCURATE PROCESSING
Provider Transaction Access No (PTAN):
NPI (10 digits):
Tax Identification Number (last 5 digits):
Provider Name:
Beneficiary Name:
Beneficiary Medicare Number (11 characters):
DCN Document Control Number:
Date(s) of service Requestor's Name (printed) Telephone Number and Extension
Procedure Code(s) in Question (required for Outpatient Services only) Requestor's Relationship to Provider
Reason for Redetermination or Clerical Error Reopening Request:
52005 (R3-23)
Print Form
Clear Form
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