MEDICARE DME Reopening Request Form
Jurisdiction A - NHIC, Corp.
Jurisdiction C - CGS
Jurisdiction B - National Government Services
Jurisdiction D - Noridian Healthcare Solutions
Supplier Information
Supplier Name
Contact Name
Tax ID
PTAN
NPI
Address
City
State
Supplier Signature
Zip Code
Phone #
Beneficiary Information
Beneficiary Name
Medicare Number
Address
City
Reason for Adjustment
Date of Service
State
Zip Code
Add/Change Modifier
Correct Number of Services
Change HCPCS Code
Correct Place of Service
Correct Date(s) of Service
Corrected Submitted Amount
Correct Diagnosis Code
Medicare Secondary Payer (MSP)
Other
HCPCS
Claim Control Number
Comments:
Fax Numbers
NHIC, Corp. 1-781-741-3914
National Government Services, Inc. 1-317-595-4737
CGS 1-615-782-4649
Noridian Healthcare Solutions 1-701-277-7886
Page 1 of 1
May 29, 2013.
© 2013 Copyright.