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MEDICARE DME Redetermination Request Form

MEDICARE DME Redetermination Request FormJurisdiction B - CGS Administrators, LLCJ urisdiction C - CGS Administrators, LLCS upplier Information Name of Person AppealingSupplier NameAddressPhone NumberPTA NBeneficiary InformationPatient NameMedicare NumberOverpayment AppealYES If yes, who requested overpayment:Medical ReviewUPICSMRCCERTR ecovery AuditorDate of ServiceHCPCS & ModifiersCCNS uggested Documentation Check List:ABNCMNDIFP hysician s Written OrderMedical DocumentationReason for AppealIf you received your initial determination notice more than 120 days ago, include your reason for the late can now submit Redetermination forms electronically!

Title: MEDICARE DME Redetermination Request Form \(DME MAC Jurisdictions B & C\) Author: CGS - CH Subject: DME MAC JB & JC Created Date: 6/3/2020 12:20:17 PM

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