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Tutorial: Completing the Medicare Part B redetermination and clerical error reopening request form
Last Modified: 3/7/2024
Location: FL, PR, USVI
Business: Part B
• Complete all information on the form in upper case letters to clearly identify the key information.
• Submit one redetermination form for each claim in question.
• Fax the redetermination and clerical error reopening request form and any supporting documentation to our office at 904-361-0595 or you may mail the request to our office. The mailing addresses are available on our
Appeals page.
DO NOT use this form if you have:
• Previously received a Medicare redetermination notice (MRN) for this claim. Your next level of appeal in this instance is Reconsideration by a Qualified Independent Contractor (QIC). Please submit your reconsideration request to the QIC address for JN. The reconsideration request form and address are listed on our
Appeals contact information page.
• A Medicare remittance notice that shows message MA-130: no appeal or reopening rights are available for this claim. Please submit a new claim with the appropriate corrections.
Our Medicare Part B Redetermination Request and Clerical Error Reopening Request form should be used if you disagree with the initial claim determination. CMS has established certain required information which must be submitted with your request in order for the Medicare administrative contractors (MACs) to complete a redetermination. Failure to provide this required information will result in your redetermination request being dismissed because it did not contain all the necessary elements.
A request for redetermination must be received within 120 days of the date of the initial claim determination. The date of initial determination is also known as the claim processing date. This date is reported on the Standard Paper Remittance (SPR) on the upper right corner with the heading date. For help in determining the date for timely filing, please use the
Appeals processing timeframes calculator.
A request for a clerical error reopening would be submitted to correct minor errors or omissions of claim specific information. CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor such as:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Computer errors
• Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate
• Incorrect data items, such as provider number, use of a modifier or date of service
Note: Clerical errors or minor errors are limited to errors in form and content, and that omissions do not include failure to bill for certain items or services. CER requests are limited to one year from the initial determination date with the exception of reporting an overpayment.
A reopening shall not be granted to add items or services that were not previously billed. Third party payer errors do not constitute clerical errors.
We have attempted to reduce the amount of information you need to type into the form by creating a series of items you can select. You should select the appropriate option from the drop-down menus to ensure your selection is properly categorized.
• Prior authorization: If the request is due to a prior authorization then select from the drop-down box either, hospital outpatient department or non-emergent ambulance.
• Jurisdiction: Please select (fill in) the appropriate state identifier for your office to avoid unnecessary delays in the handling of your request.
• FL - Florida
• VI - U.S. Virgin Islands
• PR - Puerto Rico
• RA decision question: If you are requesting a redetermination as the result of a recovery auditor decision, please select (fill in) "yes" for this question. Otherwise, select (fill-in) "no."
• 935 overpayment question: If you are requesting a redetermination as the result of a 935-overpayment decision, please select (fill in) "yes" for this question. Otherwise, select (fill-in) "no." The 935 information is located in the "Re:" section of the initial demand letter right above the provider's name, provider number, and outstanding balance.
• Medicare secondary payer (MSP) question: If you are requesting a redetermination as the result of a denial because your patient has Medicare as secondary insurance, please select (fill in) "yes" for this question. Otherwise select (fill in) "no." Please include a copy of the Explanation of Benefits from the primary insurance company with your redetermination request.
• Type of appeal: Please select (fill in) the appropriate procedure code range for the services in question.
• Procedure codes 00100-69999: If you are questioning a procedure code within this range, please select (fill in) this option.
• Procedure codes 70000-89999: If you are questioning a procedure code within this range, please select (fill in) this option.
• Chiropractic services: If you are questioning chiropractic services, please select (fill in) this option.
• Procedure code beginning with "J" or "G" or 90000-99999, or ambulance services: If you are questioning a procedure code which begins with the letter "J" or "G", the procedure code is within the code range of 90000 -99999, or an ambulance service, please select (fill in) this option.
• Other: Please select (fill in) this option if the service in question does not fit into one of the other categories.
• Identifying information: Please fill in the information below in all uppercase letters. Please pay special attention to those items identified as required. Failure to provide those items will result in a dismissal of your request for redetermination.
• Billing provider number (6 -10 digits): Provide the PTAN for the provider who is billing the service in question.
• NPI (10 digits): Please provide the NPI for the provider who is billing the service in question.
• TIN (Tax Identification Number) last five digits: Provide the last five digits of the TIN for the provider who is billing the service in question.
• Provider name: Provide the full name of the billing provider. Note: this should be the name of the entity that is tied to the billing provider number (e.g., practice name, etc.)
• Beneficiary first name: required - Provide the full first name of the beneficiary for which the service has been billed.
• Beneficiary last name: required - Provide the full last name of the beneficiary for which the service has been billed.
• Beneficiary Medicare number (11 digits): required - Provide the beneficiary's Medicare beneficiary ID number from their Medicare card. It is important to verify the name provided above and the Medicare number match and that the number is accurate. Inaccurate information could cause your redetermination request to be dismissed.
Note: Failure to provide this information will cause your redetermination request to be dismissed.
• Claim number (13 digits): The internal claim number (ICN) can be obtained from your remittance advice. This number is located on the SPR in the detail block on the same line as the patient's name. For electronic billers, the internal control number is located on the ERA in the 2100 Loop and the CLP07 Segment.
Note: If you are appealing a Part A service under a document control number (DCN), use the Part A form listed on our
Part A appeals page (DCNs include alpha characters (e.g., 123456789100101PAA)).
• Date(s) of service: required - Provide the specific dates of service(s) for the procedure code(s) in question. If there are multiple dates, please provide the range of dates in MMDDYY - MMDDYY format. You may also attach a copy of the RA or ERA circling the service(s) in question.
• Procedure code(s) in question: required - Provide the specific HCPCS code(s) for the specific service(s) in question. You may also attach a copy of the RA or ERA circling the service(s) in question.
• Requestor's name: Print the first and last name in all uppercase letters of the individual who is requesting the redetermination. This information is important should we need to contact your office for any reason.
• Requestor's relationship to provider: Print the requestor's relationship to the billing provider in all uppercase letters (examples: office manager, appeal coordinator, etc.). This information helps us validate that the requestor is a party of interest and one that we can release Protected Health Information (PHI).
• Requestor's signature: The individual identified in the "Requestor's name" block should sign, first, and last name.
• Telephone number and extension: Provide the telephone number and extension of the individual who completed the redetermination request form. This information is important should we need to contact your office regarding this appeal request.
• Reason for the redetermination or clerical error reopening request: Provide the specific reason for your redetermination or clerical error reopening request. It is important you provide the specific reason you are requesting a redetermination or a clerical error reopening and why you believe the service(s) in question should be processed in a different manner than the initial claim determination.
• Some examples include:
• We neglected to include modifier (indicate modifier to append to claim) when the claim was initially submitted.
• We believe this service is medically necessary, we did not include diagnosis (specify diagnosis code you want to append to the claim) on the initial claim submission.
• We believe this service is medically necessary, we have included documentation for your review.
• We billed the incorrect level of care, please change the procedure code to (specify correct procedure code).
• The service(s) is not related to an Automobile / Workers compensation accident, the services were for / a result of (reason the service was performed).
• This is the initial visit for the specialty of (specify provider specialty) performed by (specify name of provider), the patient has been seen before by this practice for the specialty of (specify provider specialty) performed by (specify name of provider). Attached is documentation to support both services/specialties.
• Place of service of (specify incorrect place of service) was incorrect, it should be (specify correct place of service).
• Number of services was incorrect, billed (specify incorrect number of services) should have been (specify correct number of services).
• Billing provider number of (incorrect billing provider number) was incorrect; the correct provider number should be (correct provider billing number).
• The service is not a duplicate, the times of services were (specify individual time) and (specify individual time).
• The service is not a duplicate. Please change the date of service to XX/XX/XX.
• The service should not be denied because of secondary payment. Attached is a copy of the letter of exhaustion/record of payment for this patient.
• I disagree with the overpayment because...
Missing information on forms:
• Beneficiary name
• Medicare Beneficiary ID number
• The specific service(s) or item(s) for which the redetermination is being requested
• The specific date(s) of the service
• Used to request something other than a redetermination request
• Submitted incorrectly with enrollment forms, additional documentation requests (ADRs), etc.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
