Suppliers are reminded that they also have the option of submitting Redetermination requests electronically through the Noridian Medicare Portal (NMP) without completing this form. Submit via NMP. It's fast, secure and economical - Log In Now
Paper form completion instructions are provided for each data item, which is indicated by a number. Note that data items are in groups of related information.
Based on the claims processing jurisdiction rules established by the Medicare program, parties to a claim must file a Redetermination request with the proper contractor. Jurisdiction for DMEPOS claims is established based on the state where the beneficiary resides.
Indicate the appropriate jurisdiction by checking the box to the left of the Jurisdiction name.
The fax number for each Jurisdiction is provided at the bottom left hand corner of the Redetermination Form.
| Section | Items |
| Supplier Information Section | - Name: Enter name of company/supplier
- Provider Transaction Access Number (PTAN): Enter 10-digit PTAN number assigned by National Provider Enrollment (NPE)
- National Provider Identifier (NPI): Enter 10-digit NPI number assigned by National Plan & Provider Enumeration System (NPPES)
- Tax ID: Enter 9-digit Tax ID number assigned by Internal Revenue Service
- Address: Enter supplier's billing address
- Phone number: Enter published phone number for company
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| Beneficiary Information Section | - Name: Enter name of patient (beneficiary) as it appears on their red, white and blue Medicare card
- Medicare ID: Enter the Medicare ID of patient (beneficiary) as it appears on their red, white and blue Medicare card
- State: Enter patient's (beneficiary's) permanent state of residence on file with Social Security Administration
- Phone number: Enter a contact number where patient (beneficiary) may be reached if additional patient (beneficiary) information is required
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| Contact Information for Requestor Section | - Requestor's Name/Supplier Contact Name: Print first and last name of individual requesting Redetermination. Do not enter company/supplier name. Indicate name of person that should be contacted, if additional information is required.
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| Overpayment Appeal Section | - Overpayment Appeal: If Redetermination request is result of an overpayment demand letter, indicate such by checking "Yes" box. Indicate if overpayment was identified by DME MAC Medical Review Department, Unified Program Integrity Contractor (UPIC) or Program Safeguard Contractor, Comprehensive Error Rate Testing (CERT) Contractor or Recovery Auditor by selecting appropriate box
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| Claim Information Section | - Date of Service: Enter specific date(s) of service in question
- HCPCS and Modifiers: Enter specific HCPCS code(s) and modifier(s) for which Redetermination request is being submitted (e.g., HCPCS and Modifiers indicated on original claim determination)
- Claim Control Number (CCN): Enter 14-digit claim control number listed on ERA/SPR for which Redetermination request is being submitted
- Date of Initial Determination: Enter original date of determination listed on Medicare Remittance Notice (MSN)
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| Suggested Documentation Checklist | - Suggested Documentation Checklist: Check applicable box to indicate which documentation items are being submitted with Redetermination request. If you select medical documentation, provide a description of documentation (e.g., progress notes, lab results, etc.).
Redetermination request should include all pertinent medical documentation required to support medical necessity for item/service billed. The suggested documentation list is not an all-inclusive list and should be used as a guideline only. Failure to include all supporting documentation may result in a delay in processing Redetermination request or an unfavorable decision. |
| Reason/Rationale Section | - Reasons/Rationale: Enter a detailed explanation indicating why Redetermination request is being submitted. While a detailed statement explaining reason(s) for Redetermination request is essential, the statement must be supported by documentation.
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