Tutorial: Completing the Medicare Part A redetermination and clerical error reopening request form

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Home ► Appeals ► Tutorial: Completing the Medicare Part A redetermination and clerical error reopening request form

Last Modified: 4/17/2024 Location: FL, PR, USVI Business: Part A

Tutorial: Completing the Medicare Part A redetermination and clerical error reopening request form

This tutorial has been created to assist you in completing our Medicare Part A Redetermination and Clerical Error Reopening Request Form. For your convenience this form can be completed online and printed for easy submission to our office. Additionally, if you are a portal provider you can submit your redetermination request directly through the portal.

• 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: 904-361-0593 or 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 a 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 redetermination is the first level appeal:

• It’s an independent re-examination of a claim.

• A request for redetermination must be filed within 120 days after the date of receipt of the determination notice.

This 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 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 timeliness calculator.

Outpatient facilities should use this form when requesting a reopening to correct clerical errors and omissions for denied claims. The reopening process may be used instead of requesting a formal redetermination. A clerical error reopening (a process that allows you to change claim data without submitting a written appeal) should only be requested for those situations when you are unable to enter a direct data entry (DDE) correction in the Fiscal Intermediary Shared System to correct a previously processed claim. The DDE adjustment claim should be submitted whenever possible since it is the most efficient way to correct clerical errors.

To request a clerical error reopening, please attach a revised CMS-1450 (UB-04) claim form with the requested changes circled. The claim will be reprocessed with the changes you have circled.

We reserve the right to refuse to adjust a claim as requested if the correction(s) are not clearly identified. If the initial determination cannot be changed, we cannot process the request as a reopening.

To learn more about the information that is required for each section of our form, please review the information outlined below.

Jurisdiction:

Select the jurisdiction where the claim was processed.

Question 1:

Are you requesting a clerical reopening? – Answer Yes or No

Question 2:

Does the claim you are appealing involve Medicare secondary payer? – Answer Yes or No

Question 3:

Should recoupment be stopped for a 935 overpayment? (Provide a copy of the overpayment letter) – Answer Yes or No

Question 4:

Does your appeal involve the recovery auditor decision? (Provide a copy of the overpayment letter) – Answer Yes or No

Question 5:

Did the claim you are appealing reject with message MA-130? – Answer Yes or No

Definition of remittance advice remark code MA-130: Your claim contains incomplete or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Provider Transaction Access Number (PTAN) - required:

Enter the PTAN number for the facility.

Enter the NPI for the facility.

Note: The PTAN and NPI must match the claim in question.

Tax Identification Number (last five digits):

Enter the last five digits of the facility’s tax identification number.

Provider name:

Enter the name of the provider of the services in question.

Beneficiary name - required:

Enter the beneficiary’s first and last name. Failure to provide this information will cause your request to be dismissed for insufficient information.

Beneficiary Medicare number – required:

Enter the beneficiary’s Medicare Beneficiary ID number from their Medicare card. It is important to verify the name provided and the Medicare number match and that the number is accurate. Failure to provide this information will cause your request to be dismissed for insufficient information.

Note: Failure to provide the required information will cause your redetermination request to be dismissed.

Document control number (DCN):

The DCN is the claim number, and it can be found on your standard paper remit notice in the lower right corner. For electronic billers, the DCN is located on the electronic remittance advice in the 2100 loop and the CLP07 segment.

Note: If you are appealing a Part B service under a claim number, use the Part B form listed on our Part B appeals page. (ICNs do NOT include alpha characters)

Date(s) of service:

Enter the “from and to” service dates of the claim in question as listed on the claim. Failure to provide this information will cause your request to be dismissed for insufficient information.

Procedure code(s) in question (required for outpatient services only):

Enter all procedure codes in question for outpatient services. If you have circled only specific codes on your attached claim form, you must list each code in this block. Failure to provide this information will cause your request to be dismissed for insufficient information.

Requestor’s name (printed or typed):

Enter the printed or typed first and last name of the individual who is requesting the redetermination or reopening. Failure to provide this information will cause your request to be dismissed for insufficient information.

Requestor’s relationship to provider:

Enter the relationship of the requestor to the provider of the services. This information helps us validate that the requestor is a party of interest and one to whom we can release personal history information.

Requestor’s signature (voluntary):

Signature of the individual requesting the redetermination or reopening.

Telephone number and extension:

Enter the telephone number and extension of the individual who is requesting the redetermination or reopening.

Reason for redetermination request or clerical error reopening:

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.

Common errors

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, etc.

Want to learn more?

For more information on how to request an appeal, please access this CMS resource:

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 29, section 310 external pdf file

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.