Medicare Part B Redetermination Form PDF Details

Navigating the complexities of Medicare Part B claims can feel overwhelming, especially when a service or item billed is denied, or an error is noted on the remittance notice. The Medicare Part B Redetermination and Clerical Error Reopening Request Form serves as a critical tool for healthcare providers seeking resolution. This form allows providers to request a review of an initial decision or to correct clerical errors without the need to resubmit the entire claim, provided each field is meticulously completed. Instructions stipulate its use, including a prohibition against using it for claims denied with message MA-130, indicating no appeal rights are available, thus requiring a new claim submission. The form mandates submission within 120 days of the original claim decision, and it uniquely accommodates scenarios involving prior authorization denials, overpayment decisions, and Medicare Secondary Payer situations. Required information includes provider and beneficiary details, alongside the specifics of the claim in question, such as dates of service, procedure codes, and the nature of the clerical error or disagreement with the original determination. Additionally, the form outlines the necessity of uppercase letters for certain entries, emphasizes the inclusion of remittance advice notice, and guides on the submission process. Importantly, the form also delineates when it should not be used—for example, for services already subjected to a redetermination decision, appeals concerning durable medical equipment, or overpayments not stemming from billing errors. It also carries a legal warning against the falsification of information, emphasizing the seriousness with which the form must be approached.

QuestionAnswer
Form NameMedicare Part B Redetermination Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedicare part b redetermination and clerical error reopening request form, medicare part b redetermination form, medicare redetermination form 2020, claim reopening for medicare part b online

Form Preview Example

Medicare Part B Redetermination and Clerical Error

Reopening Request Form

Submit Request via Fax: 904-361-0595

*EACH FIELD OF THE FORM MUST BE FILLED OUT TO AVOID HAVING YOUR REQUEST DISMISSED

Do not complete this form for the following situation:

Shade circles like this Not like this  

 

X

1.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.

NOTE:Requests must be filed within 120 days of original claim determination.

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: __________

1.

Does your appeal involve an overpayment decision? (Provide a copy of the overpayment letter)

__________

2.

Does the claim you are appealing involve Medicare Secondary Payer (MSP)?

__________

* The following criteria must be completed in all UPPERCASE letters:

 

Provider Name

Provider Address

 

 

 

 

 

 

Provider Transaction Access Number (PTAN)

 

Tax Identification No (last 5 digits) NPI

 

Beneficiary First Name

Beneficiary Last Name

 

 

 

Beneficiary Medicare Number (11 digits)

 

Claim Number (13 digits)

 

 

 

Date(s) of Service

Procedure Code(s) in Question

Requestor’s Name (Printed)

Requestor’s Relationship to Provider

Telephone Number and Extension

*Please include a copy of your remittance advice notice. Request for clerical error reopening

Procedure or diagnostic code submitted incorrectly:

Originally submitted as

 

Correction

Modifier omitted or submitted incorrectly:

Originally submitted as

 

Correction

Provider number submitted incorrectly:

Originally submitted as

 

Correction

Quantity billed submitted incorrectly:

Originally submitted as

 

Correction

Billed amount submitted incorrectly:

Originally submitted as

 

Correction

Zip code submitted incorrectly:

Originally submitted as

52001 (R9-20)

Correction

 

Redetermination request: Dissatisfaction with the original claim determination

The reason I disagree with the initial determination is:

This is an appeal of an overpayment request

The service was medically necessary

The service was denied as a duplicate incorrectly

The service was not overutilized

The service was denied indicating there was other insurance involvement

Additional narrative:

Please attach all pertinent documentation

q Ambulance run sheet

q History and physical

q Invoices for unlisted procedures and medication

q Diagnostic test results

q Pathology reports

q Progress notes

q Other medical records

 

Improper use of this form and additional guidance

Telephone reopenings can be requested using our interactive voice response system (IVR) at 1-877-847-4992.

Unprocessable claims denied with remittance advice message MA130 may not be appealed. Please correct the claim and resubmit.

If the service at issue has already received a redetermination decision, do not use this form. Please use the reconsideration request form located at https://medicare.fcso.com/Forms/138073.pdf.

Appeals for durable medical equipment services (DME) must be appealed to the appropriate DME Medicare administrative contractor (DME-MAC).

Overpayments resulting from billing errors or MSP/Other Payer Involvement should be reported using the overpayment refund form located at https://medicare.fcso.com/Forms/138379.pdf.

NOTICE - Anyone who misrepresents or falsifies essential information requested by this

form may upon conviction be subject to fine and imprisonment under federal Law.

PrintReset

medicare.fcso.com

First Coast Service Options Inc.

52001 (R9-20)

How to Edit Medicare Part B Redetermination Form Online for Free

It is straightforward to complete the claim reopening for medicare part b online empty lines. Our tool can make it nearly effortless to complete almost any PDF. Down below are the primary four steps you need to follow:

Step 1: Click the button "Get Form Here".

Step 2: Now, you're on the file editing page. You can add information, edit present details, highlight certain words or phrases, place crosses or checks, insert images, sign the template, erase unneeded fields, etc.

Feel free to enter the following details to prepare the claim reopening for medicare part b online PDF:

medicare part b redetermination form 2019 fields to complete

Put the required details in the Please include a copy of your, Procedure or diagnostic code, Modifier omitted or submitted, Originally submitted as, Correction, Correction, Provider number submitted, Originally submitted as, Correction, Quantity billed submitted, Originally submitted as, Correction, Billed amount submitted incorrectly, Originally submitted as, and Correction field.

Finishing medicare part b redetermination form 2019 part 2

You can be asked for some valuable information in order to fill in the The reason I disagree with the, This is an appeal of an, The service was medically necessary, The service was denied as a, The service was not overutilized, The service was denied indicating, Additional narrative, Please attach all pertinent, q Ambulance run sheet q Invoices, and q History and physical q field.

Filling out medicare part b redetermination form 2019 part 3

It is essential to indicate the rights and responsibilities of each side in space q Ambulance run sheet q Invoices, Improper use of this form and, Telephone reopenings can be, Unprocessable claims denied with, If the service at issue has, Appeals for durable medical, Overpayments resulting from, NOTICE Anyone who misrepresents, medicarefcsocom, Print, and Reset.

Filling out medicare part b redetermination form 2019 step 4

Step 3: Press the button "Done". The PDF form can be transferred. You will be able download it to your computer or send it by email.

Step 4: Be certain to remain away from possible worries by generating as much as a pair of copies of your form.

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