Get Medicare Part B Jurisdiction 15 Redetermination Request Form

The MEDICARE Part B Jurisdiction 15 Redetermination Request Form is essential for those seeking to appeal a denied claim. This guide will provide a clear, step-by-step approach to completing the form online, ensuring you provide all necessary information accurately.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Fill in the provider information section, including details such as your provider name, PTAN, NPI, and tax ID.
3. Complete the beneficiary information part by entering the patient's name, address, Medicare number, city, state, and zip code.
4. Provide the requestor's name or provider contact name and ensure to add their phone number for any follow-up communications.
5. If this is an overpayment appeal, check the corresponding box and provide the date of service relevant to the appeal.
6. List any denied CPT/HCPCS codes and modifiers related to the denied claims.
7. Include a suggested documentation checklist that supports your appeal, detailing the reasons or rationales for the redetermination request.
8. Sign and date the requestor's signature to validate the submission.
9. Review all entered information for accuracy before finalizing the form.
10. Once complete, you can save changes, download, or print the form as needed for submission.

Complete your MEDICARE Part B Jurisdiction 15 Redetermination Request Form online today to enhance your claims process.