Elements of a Redetermination Letter - JA DME

A redetermination letter contains the following informational sections.

• Opening
• Summary of Facts
• Decision
• Explanation of Decision
• Determining Liability
• Creating a Request for an Independent Appeal
• Closing

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.