Get Medicare Appeal Form

Filing a Medicare appeal can be a crucial step in addressing billing disputes and ensuring that you receive the necessary medical coverage. This guide will provide you with step-by-step instructions on how to fill out the Medicare Appeal Form effectively while ensuring a user-friendly experience.

Follow the steps to successfully complete the Medicare Appeal Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the 'Claim Information' section. Fill in the date of request, beneficiary's Health Insurance Claim Number (HICN), Provider Transaction Access Number (PTAN), and the beneficiary's name and date of birth. Ensure to provide the correct details to avoid delays in processing your appeal.
3. Enter the provider's name and address, along with the beneficiary's address. This helps to clarify who the appeal is related to and ensures proper communication from Medicare.
4. In the 'Internal Control Number(s)' field, input any relevant internal control numbers associated with your claim, followed by the procedure codes and the dates of service for the claims you are appealing.
5. Specify the billed amount for each claim. This information is critical for the review process and should match the amounts shown in your remittance advice.
6. Indicate whether your request is for redetermination or reopening. This helps Medicare categorize the type of appeal you are filing.
7. Include the date of the remittance advice for the claim in question. This date is important in establishing the timeline for your appeal.
8. Respond to whether Medicare is the primary insurer by selecting 'Yes' or 'No.' If Medicare is secondary, explain your participation status with the primary insurance company.
9. Detail the reason for your appeal or inquiry in the provided space. If applicable, include an explanation for any late filing, ensuring to provide all relevant information for Medicare's review.
10. Complete the 'Requester’s Name and Title' section along with your telephone number and the date signed. Ensure your signature is clear as it will authenticate your request.
11. Once you have filled out all sections of the form, review it to ensure accuracy. After confirming that all information is correct, you can save your changes, download the document, and print or share it as required.

Start filling out your Medicare Appeal Form online today to address your billing concerns efficiently.