Mail or fax (fax number on form) completed form to the appropriate DME contractor.
Note: Rather than completing a paper Medicare DME Reopening Request form to request a Written Reopening by mail or fax, such requests can be submitted electronically via the Noridian Medicare Portal (NMP). Read more about NMP Self Service Reopenings.
| Section | Item |
| Jurisdiction | - Check the box next to the appropriate Jurisdiction name and Contractor name
|
| Supplier Information | - Name: Enter name of company/supplier
- Contact Name: Print first and last name of individual requesting Reopening. Do not enter company/supplier name. Indicate name of person that should be contacted if additional information is required
- 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 Identification Number (TIN): Enter 9-digit Tax ID number assigned by Internal Revenue Service (IRS)
- Address: Enter supplier's billing address
- Supplier Signature: Enter signature of person requesting Reopening
- Phone: Enter a contact number of person requesting Reopening so they may be reached if additional information is required
|
| Beneficiary Information | - Name: Enter name of patient (beneficiary) as it appears on their red, white and blue Medicare card
- Beneficiary Medicare number: Enter Beneficiary (patient) Medicare number as it appears on their red, white and blue Medicare card
- Address: Enter patient's (beneficiary's) permanent residence on file with Social Security Administration
- Phone: Enter a contact number where patient (beneficiary) may be reached if additional patient (beneficiary) information is required
|
| Reason for Adjustment | - Reason for Adjustment: Mark box next to reason that best describes action being requested. Suppliers should use one form per type of Reopening form submitted.
- E.g.: add/change modifier, correct place of service, etc.
|
| Claim Information | - Claim Control Number (CCN): Enter 14-digit claim control number listed on your electronic remittance advice (ERA)/Standard paper remittance (SPR) for which the reopening is being requested
- HCPCS and Modifiers: Enter specific HCPCS code(s) and modifier(s) for which Reopening request is being submitted
- E.g.: HCPCS and Modifiers indicated on original claim determination
- Date of Service: Enter specific date(s) of service in question
|
| Comments | Comments: Enter a detailed explanation indicating why Reopening request is being submitted |
