Medicare dme reopening request form

PDF File Downloading Technical Assistance. Due to varying Internet Browsers and versions. The fax numbers for each jurisdiction are provided in the bottom left hand corner of the Reopening Request Form. Mail or fax: Complete Medicare DME Reopening Request Form. One request form per beneficiary.

If a case is identified for potential reopening and additional documentation is require MAXIMUS Federal will send the supplier an additional documentation request (ADR) letter. The supplier will have calendar days to provide the requested documentation. This request will include specific details about the information required.

Once the information is receive it will be reviewed to. This includes Medicaid claims which denied as timely filing. Submit using myCGS or hardcopy form. For a reopening with an overpayment fax to: 615.

View information about DME self service reopenings. A self service reopening or recoupment request is submitted by performing a claim status inquiry first. The Self Service Reopening link is located under Related Inquiries once the claim has been retrieved. PDF download: R250BP – CMS.

Do not complete this form for the following situations: Shade Circles like this Not like this. If you received a Medicare Redetermination Notice (MRN) on this claim DO NOT use this form to request further appeal. External Breast Prosthesis.

The “ Medicare DME MAC Redetermination Request Rorm” Note: all DME MAC regions share the same form. Helpful guide from CGS titled Reopening vs. Follow the instructions on the second page to submit the form to your carrier. You can also get this form in Spanish.

An accepted request for a claim reopening will result in a new remittance advice notification, which will list the new internal control number (ICN) for the adjusted claim. If the request for a claim reopening is not approve you will receive a letter notifying you of the decision. LeveL of appeaL … Date of the initial determination notice (please include a copy of the notice with this request ):. Timeframes to Complete a Reopening Request by a Party.

Notice of a … Medicare Secondary Payer (MSP) recovery claims where the debtor is …. Implementation Date. Request for a Medicare Prescription Drug Redetermination. On the DME MAC Reopening Request Form , suppliers do not need to complete the fields associated with the beneficiary (i.e., beneficiary name, Medicare number, address, etc.), Date of Service, HCPCS, or Claim Control Number. Palmetto GBA has forms on the eServices portal to request redeterminations or reopenings on your Medicare Part B claims.

These forms make it easier for providers to request a redetermination or reopening on a Part B claim and track that request from the date of submission through completion. For information on how to request correction of minor errors and omissions, see the Medicare Learning Network (MLN) Matters Reopening article in the Downloads section below, or refer to the Medicare Claims Processing Manual IOM 100-Chapter Reopening and Revision of Claim Determinations and Decisions (PDF).