Elements of a Redetermination Letter

A redetermination letter contains the following informational sections.

Opening

Explains what was reviewed, including HCPCS, and an overview of the decision

Summary of Facts

Provides specific details of the redetermination:

  • Provider (supplier)
  • CCNs and dates of service requested
  • Type of service(s)
  • Quantity and description of services that were paid on the claim
  • Statement with the initial determination, including the date of the initial determination
  • Date the request for the redetermination was received
  • List of all documentation submitted with the original redetermination

Decision

Provides the outcome and who is liable for the claim.

  • Note: Two separate letters may be issued if there is a medical necessity denial and non-medical necessity denial on the same claim.

Explanation of Decision

Explains the logic and specific reasons used making the decision:

  • Who reviewed the redetermination
  • What was reviewed
  • The decision made
  • Explanation of the logic/reasons that led to the decision
  • Explanation of the coverage policy (LCD, NCD), regulations, policy guidance (IOM provisions), and/or laws used to make this determination

Determining Liability

Provides information on Limitation of Liability, waiver of recovery and supplier refund requirements.

  • Note: If liability is split, the letter will specify who's responsible for which items.

Creating a Request for an Independent Appeal

Explains specific missing evidence/documentation that will be required for a possible favorable outcome at the next level of appeal (reconsideration).

Closing

Includes the examiner's name (first name and last initial) and medical review nurse name, if applicable.

 

Last Updated Nov 27, 2018