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Medicare Part B Redetermination Form – Fill Out and Use

Medicare Part B Redetermination Form is a document that your doctor must fill out when you are admitted to a facility for more than ninety days. The form helps determine if the patient will have to pay for Medicare Part B coverage.

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Medicare Redetermination Form 2020 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.

Question	Answer
Form Name	Medicare Part B Redetermination Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	medicare part b redetermination form 2019, medicare part b redetermination form 2020, medicare part b redetermination form, medicare part b redetermination

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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/
	PA	Veterans
		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
FP152 (R11-12)

Medicare Part B Redetermination Form – Fill Out and Use

Medicare Redetermination Form 2020 Details

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