Redetermination - JA DME
A Redetermination is the first level of an appeal. It is a request for independent re-examination of a claim when there is a dissatisfaction with the original determination.
Access the below Redetermination related information from this page.
- Redetermination Request Options
- Request Submission Tips
- Overpayment and Extrapolation Redetermination Request
- Good Cause for Extension
|Time Limit for Filing Request||Monetary Threshold to be Met||Time Limit to Complete Appellant's Request||Where to File||Filing Options|
120 days from initial determination date or 120 days of initial overpayment
|None||60 days from receipt date||Contractor|
NOTE: Unprocessable claims contain message MA130 ("Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.") cannot be appealed. Correct and submit as new claim.
- Access the Medicare DME Redetermination Request Form or the CMS-20027 Medicare Redetermination Request Form - One request form per beneficiary and claim control number (CCN)
- Complete all form fields. An incomplete request will be dismissed
- Send completed form and any applicable documentation (may include the Advance Beneficiary Notice of Noncoverage (ABN), office notes, operative reports, trip reports, etc.) to appropriate address or fax number
Include proper and legible documentation - Include legible medical records, prescriptions, refill requests, proof of delivery, Certificates of Medical Necessity (CMNs), DME Information Forms (DIFs), and/or the Advance Beneficiary Notice of Noncoverage (ABN) as appropriate. Do not include a corrected claim
- If medical notes are handwritten and/or illegible, the appeal will remain denied as there is no medical documentation to review. If any illegible documentation is submitted, it will be excluded as only legible pieces are considered as part of appeal request
- View the Extrapolation webpage for more information about submitting an Extrapolation Redetermination request
View the Limitation on Recoupment webpage for information regarding Section 1893(f)(2)(a) of the Social Security Act, which provides limitations on the recoupment of Medicare overpayments during the appeals process
Requests made after the 120-day time limit must include an explanation regarding the late file.
- Good cause may apply for a late filing, see CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Publication, Chapter 29 as it addresses the issue of good cause for extension of the time limit for filing appeals. If good cause is not found, request will be dismissed
Suppliers may email us with questions on the following: Timely Filing Inquiries, Appeal Regulations, Coverage Questions, Appeal Rights, Documentation Requirements for Redeterminations, Redetermination/Reopening Request Forms, Redetermination Letter Wording, Social Security Laws, Interpretation of Denial Messages, and Policies
Last Updated Mon, 08 Jul 2019 08:57:00 +0000