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.

Form NameMedicare Part B Redetermination Form
Form Length2 pages
Fillable fields40
Avg. time to fill out8 min 34 sec
Other namesredetermination form medicare part b, medicare redetermination form 2020, medicare part b redetermination, medicare part b redetermination and clerical error reopening request form

Form Preview Example

Medicare Part B Redetermination and Clerical Error

Reopening Request Form

Submit Request via Fax: 904-361-0595


Do not complete this form for the following situation:

Shade circles like this Not like this  



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: __________


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



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



Modifier omitted or submitted incorrectly:

Originally submitted as



Provider number submitted incorrectly:

Originally submitted as



Quantity billed submitted incorrectly:

Originally submitted as



Billed amount submitted incorrectly:

Originally submitted as



Zip code submitted incorrectly:

Originally submitted as

52001 (R9-20)



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

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

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

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


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 888 541 3829 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 888 541 3829 PDF:

medicare part b redetermination form 2019 fields to complete

Put the required details in the Request, for, clerical, error, reopening Provider, number, submitted, incorrectly Quantity, billed, submitted, incorrectly Billed, amount, submitted, incorrectly and Zip, code, submitted, incorrectly field.

Finishing medicare part b redetermination form 2019 part 2

You can be asked for some valuable information in order to fill in the Additional, narrative 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 Print, Reset, First, Coast, Service, Options, Inc and medicare, fc, so, com

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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