€ ational covernm nt MEDICARE CMS Mescar Aérinstatve Contractor Part B Redetermination Request Form - Level 1 DO NOT use this form to notify us of overpayments including Medicare Secondary Payer (MSP) overpayments: Save time and money, consi¢er using NGSConnex instead. Flease complete and mai ths form with all pertinent documentation (medical records, cericate of mecical necessity, ‘operative notes, Advance Beneficiary Notice of Noncoverage, eta). An denotes a required field Select the state where services were provided: Jurisdiction Oct Oma Ome Onw OnyY OR OW Jurisdictions: Qu OMN Ow [Prowserintomaton Beneticlary Information | -Name: Bais sname__[om Coen or Suc Nidhlowk Ne 1 V gEBears | smedicare Number. YY =~ TL- OR? United Sie Date of sith: _ 0} [OHA TPG “PTAN: 566% opt: _2 IG 2SCEE5D Taxi: _ 36549652. Claim Information Date of Service: From: CHM Al te: C2/0S}201 -Proceaure code:_Y53V Intemal Control Number (CH): 4 aEAaSERD sites Amount:_E\000 ‘Are you appealing an overpayment requested by National Government Services? [i Yes [] No Provide the AR Number or Letter Number (available): 23665 6 *Reason for disagreement withthe inital determination: (1 Denied as a Duplicate Incorrectly Timely Filing (explain detay in fling) Medical Necessity Dotter: WA Nate: Ts orn mabe sed or matics taal cot te cane ave. Ach ocaey lie Requester Information *Printed Name: ‘a bel Signature S Telephone Number: "OH AF Date Signed: Mail to: IK: Natonal Government Services, Inc 8: National Government Services, Ine. P.O. Box 7111 P.O, Box 6475 Incianapols, IN 48207-7111 Indianapolis, IN 46208-6475 === as