Redetermination/Reopening Form Tutorial

Move your cursor over any field in the interactive form below; you'll see instructions on how to complete the field. You may also click in any field for more detailed instructions.

Medicare JE Part A Redetermination/Reopening Form
Select the appropriate state Select the appropriate type of request Enter patient's name as it appears on the Medicare card Enter Beneficiary's date of birth Include entire Medicare number as it appears on the Medicare card The date of the remittance advice. Overpayment Demand Letter only applies to overpayment claims. Enter the entire date span of the claim as it appears on the remittance advice (RA) Indicate all the HCPCS or Procedure codes appealing Enter the AR Number or OV Demand Letter Number Enter the total amount of only the lines being appealed Enter the Document Control Number Enter the total billed charges for the entire claim Enter Provider/Facility name Enter additional diagnosis codes if applicable Enter Provider/Facility address Enter Provider Facility address cont. Enter tax identification number (TIN) Enter provider/facility's phone number Enter National Provider Identification Number Enter provider/facility's fax number Enter Provider Transaction Access Number Enter provider/facility's email address Enter the name of the contact Describe the action that needs to be addressed Requestor's signature optional Select the appropriate redetermination type Select the PO Box that corresponds with the appropriate state

 

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