Medicare Part B Redetermination Form PDF Details

Did you know that you can appeal a decision made by Medicare about your Part B coverage? If you're not happy with the decision, or if you think it was made in error, you can use the Medicare Part B Redetermination Form to try and get the decision reversed. In this blog post, we'll explain what the form is, and we'll give you some tips on how to complete it.

This information will allow you to understand better the details of the medicare part b redetermination form before starting filling it out.

QuestionAnswer
Form NameMedicare Part B Redetermination Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedicare part b redetermination form 2019, medicare part b redetermination form 2020, medicare part b redetermination form, medicare part b redetermination

Form Preview Example

MEDICARE PART B REDETERMINATION AND CLERICAL

29313

ERROR REOPENING REQUEST FORM

 

 

FAX to: 1-888-541-3829

 

 

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

Do not complete this form for the following situations:

Shade Circles like this Not like this OX O

1.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) (https://www.novitas-solutions.com/partb/forms/pdf/rrf/pdf).

2.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.

*Please select one of the following jurisdictions and select YES or NO to the questions below:

AR

CO

DCMA

DE

MS

NJ

NM

OK

1.Does your appeal involve the Recovery Auditor (RA) decision?

2.Does your appeal involve a 935 overpayment decision?

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

LA

 

MD

 

PA

TX/IHS/

 

Veterans

 

 

Yes

 

No

Yes

 

No

Yes

 

No

*Please select one of the choices below to identify the category which the request pertains to:

Procedure Codes 00100-69999

 

Procedure Codes 70000-89999

Chiropractic Services

Procedure code beginning with "J" or "G" or 90000-99999 or Ambulance Services

Other

*Please fill in the information below in all UPPERCASE letters:

 

 

 

Billing Provider Number (up to 10 digits):

NPI (10 digits):

Tax Identification Number (last 5 digits):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Requestor's Signature

Telephone Number and Extension

*Reason for Redetermination or Clerical Error Reopening Request:

FP152 (R11-12)

29313

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Watch Medicare Part B Redetermination Form Video Instruction

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