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

Last Updated Sep 08, 2017