Redetermination Request Checklist

Yes/No Requestor Action
 
  • Review Standard Paper Remittance (SPR) or Medicare Electronic Remittance Advice (ERA) for claim(s) you are requesting a Redetermination on. Is ERA or SPR from Noridian?
    • If not, submit request for Redetermination to appropriate Durable Medical Equipment Medicare Administrative Contractor (DME MAC) identified on ERA or SPR
 
  • Was the claim(s) in question denied with an appealable ANSI code?
    • If not, claim(s) denied as unprocessable and supplier must correct and resubmit claim(s)
  • Does the ERA or SPR indicate a remittance advice remark code of MA01?
    • If so, appeal rights are available.
 
  • Is claim denial due to a minor clerical error or omission (e.g., units of service, service dates, HCPCS coding, diagnosis codes, etc.)?
    • If so, submit a Reopening request. It can be submitted in writing through mail, fax or via Telephone Reopenings.
 
  • What was date of final determination indicated on ERA or SPR? Have more than 120 days lapsed since the final determination?
    • If so, requestor must provide "good cause" detailing reason for filing late.
 
  • Have you reviewed all information listed above? If so, you are now ready to complete a Redetermination form and submit a request. See Mailing Addresses for submission address.

 

Although the Redetermination Request Form and the CMS form 20027 are not required; they are highly recommended. If you decide not to use either of these suggested forms, you must submit, at minimum, the following elements.

  • Beneficiary's Name
  • Beneficiary's Medicare ID
  • Specific service(s) and/or item(s) and specific date(s) of service in question
  • First name and last name of person filing request

Note: Incomplete requests will be dismissed with an explanation of missing information. Requestors will be instructed to resubmit their request with all of missing information.

 

Last Updated Mon, 08 Jul 2019 09:08:06 +0000