Redetermination/Reopening Form Instructions

If questions arise when completing a Redetermination/Reopening Form, please see the below.

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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
ICN Enter Internal Control Number (ICN)
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 ICN *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 including area code
Fax Number Enter Provider/Facility's fax number
Provider Email Address Enter Provider/Facility's email
Requestor's Signature Handwritten signature in dark ink (Required on all requests)
Noridian Address Select appropriate Redetermination type
PO Box Select PO Box that corresponds with applicable state

 

Last Updated Oct 23, 2018