Get Overpayment Redetermination Request Form Flb - Fcso

Filling out the Overpayment Redetermination Request Form FLB - FCSO is a straightforward process that allows service providers to contest an overpayment determination securely. This guide will walk you through each section of the form, ensuring you submit your request accurately and effectively.

Follow the steps to complete your Overpayment Redetermination Request form.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. In block 1, enter the carrier’s name and address indicated in the form. Ensure accuracy to avoid delays in processing.
3. In block 2, provide the name of the patient as it appears on their Medicare card, including the last name, first name, and middle initial if available.
4. Enter the Medicare Health Insurance Claim Number (HICN) in block 3, as displayed on the patient's Medicare card. This number is crucial for identifying the claim.
5. In block 4, indicate the 13-digit accounts receivable number found on the overpayment request letter or the Health Data Insight Request form.
6. For block 5, list all Internal Control Numbers (ICNs) associated with the claim. If multiple ICNs are involved, indicate 'multiple' and attach a comprehensive list.
7. In block 6, select the reason(s) for your disagreement with the initial decision by checking the appropriate boxes. Be specific if you choose 'OTHER' and provide detailed information.
8. Block 7 requires you to detail the service dates and procedure codes in question. Use one line for each date range with its corresponding procedure code, ensuring clarity.
9. In block 8, supply any additional relevant information, such as specific diagnoses or conditions related to the claim. This context may influence the re-evaluation process.
10. Block 9 allows you to check which attachments you are including with your form. Clearly identify the materials to ensure all necessary documentation is considered.
11. Finally, in block 10, sign the form either printed or written, and provide a contact telephone number to facilitate any necessary follow-up.
12. After completing all fields, users can save changes, download, print, or share the filled form as needed.

Submit your Overpayment Redetermination Request form securely online today.