Get 155 0913 Part B Appeals Form 5081

Completing the 155 0913 Part B Appeals Form 5081 online is a straightforward process that allows users to appeal decisions related to Medicare claims. This guide provides clear and supportive instructions to help you navigate each section effectively and ensure your appeal is submitted correctly.

Follow the steps to fill out your appeal form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the 'Date of Request' field, providing the date you are submitting your appeal. This ensures that your request is processed in a timely manner.
3. Next, enter the 'Beneficiary HICN' field, including the Health Insurance Claim Number for the person affected by the claim.
4. In the 'PTAN Number' section, input the Provider Transaction Access Number relevant to your case.
5. Complete the 'Beneficiary Name' and 'Beneficiary Date of Birth' fields with accurate personal details.
6. Fill out the 'Provider Name and Address' section with accurate information regarding your healthcare provider.
7. Include the 'Beneficiary Address' to ensure the correspondence is directed to the right individual.
8. In the 'Internal Control Number(s)' field, input any control numbers associated with your claim.
9. Provide the relevant 'Procedure Code(s)' and 'Date(s) of Service', clearly indicating when the medical services were provided.
10. In the 'Billed Amount' section, state the amount billed to Medicare for the services rendered.
11. Select the type of request you are making by checking either 'Redetermination' or 'Reopening'.
12. Record the date of the remittance advice for the claim in question as this can affect the processing of your appeal.
13. Indicate if Medicare is your primary insurance by selecting 'Yes' or 'No'.
14. If your appeal involves a secondary payment, specify whether you participate in the primary insurance company by choosing 'Participate' or 'Do not participate'.
15. In the 'Reason for appeal/inquiry' field, provide a detailed explanation for your appeal and, if applicable, include the reason for any late filing.
16. Fill in 'Requester’s Name and Title', ensuring that your contact information is complete, including your 'Telephone Number'.
17. Finally, sign and date the form in the designated areas to validate your request. Ensure that your signature matches the name you provided.
18. Once all information has been entered correctly, you can save your changes, download, print, or share the completed form as needed.

Take the next step in your healthcare journey by completing the 155 0913 Part B Appeals Form 5081 online today.