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

 

Redetermination Request Options

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

  • View the Extrapolation webpage for more information about submitting an Extrapolation Redetermination request
  • View the Limitation on Recoupment webpage for information regarding Section 1893(f)(2)(a) of the Social Security Act, which provides limitations on the recoupment of Medicare overpayments during the appeals process

Good Cause for Extension

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 Oct 18, 2018