Get Medicare Je Part A Redetermination/reopening Form

This guide will walk you through the process of filling out the Medicare JE Part A Redetermination/Reopening Form online. Understanding how to complete this form is essential for effectively appealing a Medicare claim determination.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Medicare JE Part A Redetermination/Reopening Form in your preferred editor.
2. Identify the type of request you are making by selecting the appropriate checkbox—options include redetermination, overpayment redetermination, RAC, or ZPIC.
3. Indicate your state of residence from the provided options.
4. Determine if your request is within the 120-day time frame by selecting 'Yes' or 'No.' If 'No,' you must provide a valid reason or evidence for good cause.
5. Fill out the required patient information, including patient name, date of initial determination, Medicare number, and date of birth.
6. Provide the date(s) of service and complete the sections for HCPCS or procedure codes, NPI number, tax ID number, DCN number, and telephone number.
7. Complete the provider information, including PTAN number, provider address, provider name, and state.
8. Enter details for the contact person, including their city, fax number, and zip code.
9. In the action request/comments section, specify the details of your request.
10. Sign the form in the designated area to confirm your request.
11. Ensure you attach all necessary supporting documentation relevant to your appeal, as specified.
12. If submitting by mail, select the correct PO Box for your request type, as choosing the incorrect box may cause delays.
13. After filling out the form, save your changes, download the completed form, or print it for your records.

Complete the Medicare JE Part A Redetermination/Reopening Form online today for a smoother appeals process.