Fillable First Coast Service Options - Request for Redetermination of a Part B Claim Florida

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First Coast Service Options - Request for Redetermination of a Part B Claim Florida

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The First Coast Service Options - Request for Redetermination of a Part B Claim Florida form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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Medicare Part B request for redetermination or reopening form -- Florida
Requests must be filed within 120 days of original claim determination. If request is filed after the 120-day timeframe, please include
your reason for not making this request earlier. Please complete one request form for each claim. Please include only the specific item
(s) or service (s) for which the redetermination is being requested.
Submit requests to:
First Coast Service Options
P. O. Box 2360
Jacksonville, FL 32231-0018
Please complete each field on the form to ensure accurate processing
Correction
Beneficiary name:
Medicare ID number:
Internal Control Number (ICN):
Date of service:
CPT®/HCPCS code:
Name of claimant or representative:
Phone number of claimant or representative:
Request for clerical error reopening
Procedure or diagnostic code submitted incorrectly: Originally submitted as
Correction
Correction
Correction
Correction
Correction
Modifier omitted or submitted incorrectly:
Originally submitted as
Originally submitted as
Originally submitted as
Originally submitted as
Originally submitted as
Provider number submitted incorrectly:
Quantity billed submitted incorrectly:
Billed amount submitted incorrectly:
ZIP code submitted incorrectly:
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Redetermination request: Dissatisfaction with the original claim determination
The reason I disagree with the initial determination is:
This is an appeal of an overpayment request
The service was medically necessary
The service was denied as a duplicate incorrectly
The service was not overutilized
The service was denied indicating there was other insurance involvement
Additional narrative:
Please attach all pertinent documentation
Ambulance run sheet History and physical
Invoices for unlisted procedures and medication Diagnostic test results
Pathology reports Progress notes
Other medical records
Improper use of this form and additional guidance
Telephone reopenings can be requested using our interactive voice response system (IVR) at 1-877-847-4992.
Unprocessable claims denied with remittance advice message MA130 may not be appealed. Please correct the claim and resubmit.
If the service at issue has already received a redetermination decision, do not use this form. Please use the reconsideration request form
located at https://medicare.fcso.com/Forms/138073.pdf.
Appeals for durable medical equipment services (DME) must be appealed to the appropriate DME Medicare administrative contractor (DME
MAC).
Overpayments resulting from billing errors or MSP/Other Payer Involvement should be reported using the overpayment refund form
located at https://medicare.fcso.com/Forms/138379.pdf.
NOTICE - Anyone who misrepresents or falsifies essential information requested by this
|form may upon conviction be subject to fine and imprisonment under Federal Law.
Form revised 10/1/2019
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First Coast Service Options - Request for Redetermination of a Part B Claim Florida

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Completed 24 May 2020

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