Cahaba Gba Clerical Error Reopening Request Form

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Cahaba GBA Clerical Error Reopening Request Form
Instructions: This form should be used to submit a minor clerical error 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 reopening request to the appropriate
address below.
Select State:
Alabama Medicare Part B
Georgia Medicare Part B
Tennessee Medicare Part B
Mississippi Medicare Part B
Clerical Error Reopenings
Clerical Error Reopenings
Clerical Error Reopenings
Clerical Error Reopenings
P.O. Box 830140
P.O. Box 12847
P.O. Box 12086
P.O. Box 547
Birmingham, AL
Birmingham, AL
Birmingham, AL
Birmingham, AL
35283-0140
35202-2847
35202-2086
35201
Provider Information:
Name:
NPI/PTAN Provider #:
Address:
Phone #:
Beneficiary Information:
Name:
Medicare #:
Address:
Phone #:
Service Date:
CPT/HCPCS:
Internal Control Number (ICN):
Reason for Request: (Select all that apply)
The Diagnosis was not linked properly on the original claim.
The number of services or units is incorrect or missing.
The anesthesia time is missing.
The date of service is incorrect (except for changes to the year).
The CPT code is incorrect, and changing it will not create an overpayment.
The services are incorrectly denied as duplicate charges.
A modifier is being added or corrected (except for Returned Unprocessable Claim (RUC)-MA-130 denials).
The place of service is incorrect
Injection name and dosage (for miscellaneous codes).
Ambulance services to add modifier GW only when denied for hospice care.
Form Completed by:
Signature: ____________________________________
Date: _____________
Cahaba Government Benefit Administrators®, LLC, J10 A/B Medicare Administrative Contractor
09/2009

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