Form 52001 at a glance
What it is: Form 52001 (3.12.26) is the Medicare Part B Redetermination Request Form, for a redetermination request.
Where and when to file: Submit the Request via Fax: 904-361-0595.
A filled-in Form 52001 example: a billing clerk requests a redetermination
How to fill out Form 52001, box by box
Prior-Authorization denial
If this request is due to a Prior-Authorization denial, select from the drop down.
Jurisdiction and the YES or NO questions
Select one of the jurisdictions and select YES or NO to the questions.
Does your appeal involve the Recovery Auditor (RA) decision?
Does your appeal involve a 935 overpayment decision?
Does the claim you are appealing involve Medicare Secondary Payer (MSP)?
Category which the request pertains to
Select one of the choices to identify the category which the request pertains to.
Provider, beneficiary, claim, service and requestor information in all UPPERCASE letters
Fill in the information in the boxes of the form page in all UPPERCASE letters.
Enter the Provider Transaction Access No (PTAN), the NPI (10 digits), the Tax Identification Number (last 5 digits) and the Provider Name.
Enter the Beneficiary First Name and the Beneficiary Last Name.
Enter the Beneficiary Medicare Number (11 characters) and the Claim Number (13 digits).
If the Claim Number is alpha-numeric, use the Part A request form.
Enter the Date(s) of service and the Procedure Code(s) in Question.
Enter the Requestor’s Name (Printed) and the Requestor’s Relationship to Provider.
Enter the Telephone Number and Extension.
Reason for Redetermination Request
Enter the Reason for Redetermination Request.
Do not complete this form for the following situations
Medicare Redetermination Notice (MRN)
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.
Message MA-130 on the Medicare Remittance Notice
If you received a message MA-130 on the Medicare Remittance Notice for this claim, do not complete this form: no appeal or reopening rights are available. Submit a NEW claim with the appropriate corrections.
Before you go
Complete each field on the form to ensure accurate processing.
Common questions about Form 52001
Where do I file it?
Submit the Request via Fax: 904-361-0595.
Sources
[1] Form 52001 (3.12.26), Medicare Part B Redetermination Request Form (the Official source link on this page).
