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! Visit the Reprocessing tab in myCGS to submit a form and see status of a Redetermination . NumbersCGS Administrators, LLC - JB Administrators, LLC - JC 1 of 1 | Revised June 3, 2020 | 2020 Copyright, CGS Administrators, LLC.

MEDICARE DME Redetermination Request Form Jurisdiction B - CGS Administrators, LLC Jurisdiction C - CGS Administrators, LLC Supplier Information Name of Person Appealing Supplier Name Address Phone Number PTAN Beneficiary Information Patient Name Medicare Number Overpayment Appeal YES If yes, who requested overpayment: Medical Review UPIC …

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Transcription of MEDICARE DME Redetermination Request Form

1 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! Visit the Reprocessing tab in myCGS to submit a form and see status of a Redetermination . NumbersCGS Administrators, LLC - JB Administrators, LLC - JC 1 of 1 | Revised June 3, 2020 | 2020 Copyright, CGS Administrators, LLC.