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  • Wps Gha Part B Redetermination Request Form

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WPS GHA PART B REDETERMINATION REQUEST FORMAll fields are REQUIRED State service was performed in: IA KS MO NEProvider Information (requests with incomplete information will be dismissed) Provider.

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A redetermination must be requested in writing....Make a written request containing all of the following information: Beneficiary name. Medicare number. Specific service(s) and/or item(s) for which a redetermination is being requested. Specific date(s) of service. Name of the party, or the representative of the party.

Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).

If you disagree with a Medicare coverage or payment decision, you can appeal the decision. The MSN contains information about your appeal rights. You'll get a MSN in the mail every 3 months, and you must file your appeal within 120 days of the date you get the MSN.

What's it used for? Requesting an appeal (redetermination) if you disagree with Medicare's coverage or payment decision.

Faxing Your Redetermination Request — You can fax the redetermination request to us along with the documentation that is needed to determine if the services are medically necessary and covered under Medicare's guidelines.

Fill out a "Redetermination Request Form [PDF, 100 KB]" and send it to the company that handles claims for Medicare. Their address is listed in the "Appeals Information" section of the MSN. Or, send a written request to company that handles claims for Medicare to the address on the MSN.

Explain in writing why you disagree with the decision or write it on a separate piece of paper, along with your Medicare number, and attach it to the MSN. Include your name, phone number, and Medicare Number on the MSN. Include any other information you have about your appeal with the MSN.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232