Please rate Medicare Part B Redetermination Form 3.12.26
Submit Request via Fax: 904-361-0595. Please complete each field on the form to ensure accurate processing.
MA-130: If you received a message MA-130 on the Medicare Remittance Notice for this claim, no appeal or reopening rights are available.
Next appeal level: Your next level of appeal is a Reconsideration by a Qualified Independent Contractor (QIC) - Form.
Letters: Please fill in the information below in all UPPERCASE letters.
Claim number: Claim Number (13 digits): If alpha-numeric use Part A request form.
| Question | Answer |
|---|---|
| Form Name | Form 52001 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 22 |
| Avg. time to fill out | 4 min |
| Edition | 3.12.26 |
| Where to send | Submit Request via Fax: 904-361-0595 |
| Other names | 52001, Form 52001, Medicare Part B redetermination request form, Medicare redetermination form |
| Official source | Form 52001 (Rev 3.12.26), |
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Please rate Medicare Part B Redetermination Form 3.12.26
