Billing, Claims, and Appeals

Tell us what you think

Chat bubble and question mark image

Your comments will help us improve our services.

Take the Redeterminations Survey

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. Most reopenings can be submitted through the Noridian Medicare Portal or in writing through mail, fax. Some still require a telephone reopening.
 
  • 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.

 

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 when mailing or faxing, 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 Nov 2021 19:26:14 +0000