MEDICARE Part A Jurisdiction 15 Redetermination Request Form
Provider Information
OHIO - (15201)
Provider Name:
KENTUCKY - (15101)
PTAN:
NPI:
Address:
Patient Name:
City:
Medicare Number:
Zip Code:
State:
Phone Number:
Requestor’s Name/Provider Contact Name:
Signature must be hand-written
Requestor’s Signature:
Overpayment Appeal:
If yes, then check:
Date of Service:
MR
ZPIC
Date of Initial Determination:
CERT
DCN:
RAC
Denied Services:
Note: Only one claim number per form should be submitted. Multiple claims per submission will not
be acknowledged for processing.
Suggested Documentation Checklist:
Reasons/Rationale:
CGS
Attn: J15 Part A Appeals Department
PO Box 20006
Nashville, TN 37202
Fax: 1-803-462-2585
Revised February 28, 2014.
© 2014 Copyright, CGS Administrators, LLC.
Medicare Remittance Advice
Advance Beneficiary Notice
Physician’s Written Order
Signed Medical Documentation
Other