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
  • 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 Jul 08, 2019