Redetermination Request Form

MEDICARE DME Redetermination Request FormSupplier Information Supplier NamePTA NNPITa x I DBeneficiary InformationAddressPatient NameCityMedicare NumberStateZip CodeStatePhone NumberPhone NumberRequestor s Name/Supplier Contact NameRequestor s Signature (required)DateOverpayment Appeal Yes If yes, who requested overpayment: Medical Review ZPIC/UPIC SMRC CERT Recovery AuditorDate of ServiceHCPCS & ModifiersCCNDate of Initial DeterminationSuggested Documentation Check List: Medicare Remittance Advice CMN/DIF/Physician s Written Order ABN Medical DocumentationReasons/RationaleFax NumbersNoridian Healthcare Solutions - JA 1-701-277-2425 CGS Administrators, LLC - JB 1-615 - 660-5976 CGS Administrators, LLC - JC 1-615-782-4630 Noridian Healthcare Solutions - JD 1-701-277-7886 Page 1 of 1 June 21, 2017.

Title: Redetermination Request Form Author: CGS - CH Subject: DME All Jurisdiction Created Date: 6/21/2017 8:30:51 AM

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