f { fiecoray Covernment MEDICARE Part B Redetermination Request Form — Level 1 [ACMS Medicare Administrative Contractor DO NOT use this form to notify us of overpayments including Medicare Secondary Payer (MSP) overpayments ‘Save time and money, consider using NGSConnex instead. Please complete and mail this form with all pertinent documentation (medical records, certificate of medical necessity, operative notes, Advance Beneficiary Notice of Noncaverage, etc.). An * denotes a requited field. Select the state where services were provided: JurisdictionK: []CT CMA (JME CNH ONY ORI Dvr Juri iné: Cit OMN wi Provider information Beneficiary Information *Name:_Z7IUALin. Tow *Name:_ ak Address: “Medicare Number: = Uft= Mh aah oak vee oon, (21021 40 “PTAN. = a Claim information “Date of Service: From: TL UA To: | WALQA__*Procedure Code: 32444 Internal Control Number (ICN): TSOO M3 RA3_ Billed Amount_\OOO0 ‘Are you appealing an overpayment requested by National Government Services? [ZLYes [] No Provide the AR Number or Letter Number (if available): “Reason for disagreement with the initial determination: Denied as a Duplicate Incorrectly C1 Timely Filing (explain delay in filing) (1 Medical Necessity 0 Other: "Note: This form may be used for multiple claims thal all contain the same issue. Attach a coy of the RA and indicate which claims should be corectd. Requester Information 3 : “Printed Name: ‘Abe Aworsia Signature: tab age Telephone Number: _YY6 “262-6422 _ date signed: ALU Mail to: JK: National Government Services, Inc. J8: National Government Services, Inc. P.O. Box 7111 P.O, Box 6475 Indianapolis, IN 46207-7114 Indianapolis, IN 46206-6475 ‘National Government Serves, nc 1058. 11872019, —_——