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This page allows you to enter medical details related to your amended re-review request.
This page displays:
Case Number: The Case Number for re-review.
Re-Review Type: Displays the type of re-review you selected on the Case Re-Review Request page. Options are:
- Medical
- Both (Medical and Drug)
To continue with your re-review request, you must provide medical reasons showing that your care has changed enough to warrant an amended review. Use the sections below to provide these reasons. You must identify at least one medical line item, or add at least one additional care line item to continue.
Reminder:
Medical Line Item Identification and Justification
This section displays all medical line items contained on the CMS Recommendation Sheet that was included with the Approval letter for this case. Use this section to indicate which (if any) of these items have changed since the case was approved. To indicate changes:
- Select the radio button(s) for each item to indicate if it has already been provided to the beneficiary, or if the item is no longer required.
- Enter up to 75 characters in the If item is selected, provide references to records describing this change field.
Use this field to indicate which records (existing or additional) contain references to the type of changes indicated by items you selected.
Note: Use the scroll bar to view additional line items.
Justification for Re-Review
| Field | Description |
| This item has already been provided to the beneficiary | Radio button. Select this button to indicate that the care in this line item has already been provided to the beneficiary. |
| This item is no longer required | Radio button. Select this button to indicate that due to changes in care, the care indicated in this line item is no longer required. |
| Line Item from CMS Recommendation Sheet included with Approval Letter | Read only. Displays the medical line item contained on the CMS Recommendation Sheet that was included with the Approval letter for this case. |
| If item is selected, provide references to records describing this change | Enter free-form text (up to 50 characters) to refer to the records that contain information about this line item. This field is required if you make a radio button selection. Do not enter text in this line if you did not select a radio button. |
Additional Care Line Items
You can add additional line items for care that was not listed in the Medical Line Item Identification section. To add additional care items:
- Click Add to add a new line to the table.
- Click to enter up to 75 characters in the Describe Additional Care field.
Use this field to provide a short description of the additional care. - Click to enter up to 75 characters in the Provide references to records describing this additional care field.
Use this field to indicate which records (existing or additional) contain references to the additional care. - To delete a line item, click Delete.
Additional Care Line Items
| Field | Description |
| Describe Additional Care | Enter freeform text (up to 75 characters) to provide a short description of the additional care. |
| Provide references to records describing this additional care | Enter freeform text (up to 75 characters) to refer to the records that contain information about this line item. |
| Add | Click to add a new line item. |
| Delete | Click to delete a line item. |
Click Previous to return to the Case Re-Review Request page.
Click Continue to continue with the request to display the:
- Case Amended Review Case Documents page, if you selected "Medical" as the re-review request type, or
- Case Re-Review Request Drug Details page, if you selected "Both" as the re-review request type.
Click Cancel to cancel the re-review request and display the Cancel Re-Review Request Confirmation page.
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