Redetermination/Reopening Form Instructions
If questions arise when completing a Redetermination/Reopening Form, please see the below.
Last Updated Oct 24, 2018
If questions arise when completing a Redetermination/Reopening Form, please see the below.
|Form Field||Brief Description|
|State||Select appropriate state|
|Type of Request||Select appropriate type of request|
|Patient Name||Enter patient's name as it appears on Medicare card|
|Medicare Number||Include complete Medicare alpha/numeric as it appears on Medicare card|
|Date(s) of Service||Enter entire date span of claim as it appears on Remittance Advice (RA)|
|HCPCS/Procedure Codes||Indicate all HCPCS or CPT codes included in request|
|DCN||Enter Document Control Number (DCN)|
|Provider Name||Enter Provider/Facility name|
|Provider Address||Enter Provider/Facility address|
|City, State, Zip||Enter Provider Facility address|
|NPI Number||Enter National Provider Identification (NPI)|
|PTAN Number||Enter Provider Transaction Access Number (PTAN)|
|Contact Person||Enter name of contact|
|Action Request/Comments||Describe action to be addressed|
|Date of Birth||Enter Beneficiary's date of birth|
|Initial Determination or Overpayment Demand Letter Date||Date of RA Overpayment Demand Letter only applies to overpayment claims|
|AR Number or OV Demand Letter Number||Enter DCN *Only applies to overpayments|
|Billed Amount of the Code(s) to be Reviewed||Enter total amount of lines included in request|
|Total Claim Billed Amount||Enter total billed charges for entire claim|
|Diagnosis of Services Appealed||Enter additional diagnosis codes, if applicable|
|Tax ID Number||Enter Tax Identification Number (TIN)|
|Telephone Number||Enter Provider/Facility's phone number|
|Fax Number||Enter Provider/Facility's fax number|
|Provider Email Address||Enter Provider/Facility's email|
|Requestor's Signature||Requester's Signature (Required)|
|Noridian Address||Select appropriate Redetermination type|
|PO Box||Select PO Box that corresponds with applicable state|
Last Updated Oct 24, 2018
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End User License Agreement
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