Elements of a Redetermination Letter

A redetermination letter contains the following informational sections.


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


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).


Includes the examiner's name (first name and last initial) and medical review nurse name, if applicable.


Last Updated Oct 15 , 2021