Fillable Part B Redetermination Request Form - Level 1 printable pdf download

MEDICARE

Part B Redetermination Request Form – Level 1

A CMS Medicare Administrative Contractor

Please complete and mail this form with all pertinent documentation (medical records, certificate of medical necessity,

operative notes, Advance Beneficiary Notice, etc.). An * denotes a required field.

Select the state where services were provided:

Jurisdiction K:

Jurisdiction 6:

Provider Information

Beneficiary Information

Name: ___________________________________

*Name: __________________________________

Address: __________________________________

Address: _________________________________

_________________________________________

________________________________________

PTAN: ___________________________________

*Medicare Number: ________________________

NPI: _____________________________________

Date of Birth: _____________________________

TAX ID: __________________________________

Claim Information

*Date of Service: From____________ To: ____________ *Procedure Code _______________________

Internal Control Number (ICN): _____________________ Billed Amount __________________________

Yes

No If no, are you participating with the primary?

Yes

Is Medicare Primary?

Yes

Does this appeal involve an overpayment?

Provide the AR number or Letter Number (if available): _________________________________________

Reason for disagreement with the initial determination:

Denied as a duplicate incorrectly

Medicare Secondary Payer

Medical Necessity

Timely Filing (explain delay in filing)

Other: ______________________________________________________________________________

_______________________________________________________________________________________________

Note: This form may be used for multiple claims that all contain the same issue. Attach a copy of the RA and indicate which claims should be corrected.

Requester Information

*Printed Name: _____________________________ *Signature: _________________________________

Telephone Number __________________________ Date Signed: _______________________________

Mail to:

JK: National Government Services, Inc.

J6: National Government Services, Inc.

P.O. Box 7111

P.O. Box 6475

Indianapolis, IN 46207-7111

Indianapolis, IN 46206-6475

The legal authority for the collection of information on this form is authorized by section 1869 (a)(3) of the Social Security Act. The information provided will be

used to further document your claim. Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested

information may affect the determination of your claim. Information you furnish on this form may be disclosed to the Centers for Medicare and Medicaid Services

or another person or government agency only with respect to the Medicare Program and to comply with Federal laws requiring or permitting the disclosure of

information or the exchange of information between the Department of Health and Human Services and other agencies.

National Government Services, Inc.

1655_0415