Fillable Part A Clerical Error Reopening Request Form printable pdf download

Part A Clerical Error Reopening Request Form

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Part A Clerical Error Reopening Request Form

Instructions: Please use this form for Part A claims only (claims processed in the Fiscal Intermediary Standard System (FISS). This

form should be used to submit a Part A minor clerical errors or omission for both contractor and provider errors. Complete this request

by typing information directly on the form for each claim you wish to submit. After typing the information, print the form, sign it and

send your clerical error reopening request to the appropriate address listed below.

Alabama J10

Georgia J10

Tennessee J10

Cahaba GBA

Part A Adjustments

P.O. Box 830139

P.O. Box 830867

P O Box 11465

Birmingham, AL 35283-0139

Birmingham, AL 35283-0867

Birmingham, AL 35202-1465

Complete a new “Cahaba GBA Part A Clerical Error Reopening Request” form for each claim you wish to reopen.

Beneficiary’s name: _____________________________________________________________________________________

Medicare number: ______________________________________________________________________________________

Date of the initial determination notice: ____________________________________________________________________

Date of Service: (required): Date signed: ____________________________________________________________________

Please check the minor clerical error or omission you wish to correct:

Change in total charges

Change in patient status

Change in date of service

Adding late charges

(A revised claim form (UB-04) with the requested changes CIRCLED or noted with an ASTERISK)

MUST be

attached.

Cancel claim/claims request (reason must be indicated)

Other: __________________________________________________________________________________________

___________________________________________________________________________________________________

Remember to attach supporting documentation.

Requestor’s Name ______________________________________________________________________________________

Requestor’s Address: ____________________________________________________________________________________

Requestor’s Telephone Number: __________________________________________________________________________

Requestor’s Relationship to Beneficiary: ____________________________________________________________________

Requestor’s Signature: __________________________________________________________________________________

Date signed: ___________________________________________________________________________________________

Cahaba Government Benefit Administrators®, LLC, J10 A/B Medicare Administrative Contractor

A CER Form

02/2012

Part A Clerical Error Reopening Request Form

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