Redetermination

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.

 

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

Calculate Submission Timeline

None 60 days from receipt date Contractor

 

Request a Redetermination

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.

Electronic Submission

  • Submit via NMP. It's fast, secure and economical - Log In Now
    • Access educational resources, learn how to register and view user manual on NMP webpage

Paper Submission

  • 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
    • Accept electronic, typed, handwritten (must be in dark ink), scanned and digital and/or digitized signatures on the form
  • 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

Request Submission Tips

  • 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
  • Include valid appellant signatures - Requests received without appellant's signature are dismissed as incomplete requests

Overpayment and Extrapolation Redetermination Request

  • To appeal overpayment, check "Yes" in Overpayment Appeal section of "Medicare DME Redetermination Request Form" or "Does this appeal involve and overpayment?" box in CMS-20027 "Medicare DME Redetermination Request Form"
  • Include a copy of overpayment letter
  • Send request to specific Post Office Box for "Overpayment Redetermination and Rebuttal Requests"
    • Submit Extrapolation Redetermination requests. View Extrapolation webpage for more information

Time Limit for Filing a Request and Good Cause for Extension

  • 120 days of initial claim determination date (date on Medicare Remittance Advice (RA) or beneficiary's Medicare Summary Notice (MSN))
    • A request filed is considered to be filed the date the MAC receives it. The time limit for a request is computed by allowing five additional days beyond the time limit from the RA or MSN date. This allows a 5-day period for mail delivery
    • When filing deadline ends on a Saturday, Sunday, legal holiday, or any other nonwork day, the contractor shall apply a rollover period that extends filing deadline to first working day after the Saturday, Sunday, legal holiday, or other nonwork day. Example: Filing deadline falls on Saturday before Columbus Day, filing deadline is then extended to first working day after Columbus Day holiday
  • Requests made after the 120-day time limit must include an explanation regarding the late file

Email Us

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 Feb 14, 2018