The first level of an appeal, a redetermination, is a request to review a claim when there is a dissatisfaction with the original determination. A redetermination is an independent re-examination of an initial claim determination. If a party or representative is dissatisfied with the decision on a claim, a redetermination may be requested. The redetermination must be requested in writing or by fax or electronic submission.

Who Can Request a Redetermination

• Beneficiary
• Representative payee for the beneficiary
• Physician or supplier accepting assignment
• Physician or supplier not accepting assignment, if the service is denied for medical necessity
• Physician or supplier not accepting assignment, if he has a signed authorization or signed non-assigned Medicare Summary Notice (MSN)
• Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations

Requesting a Redetermination

Noridian encourages the use of the DME Inquiry/Redetermination Form to ensure all requirements are included or suppliers may write a letter including the following information:

• Clear statement explaining the error or omission
• Beneficiary name
• Medicare Health Insurance Claim Number (HICN)
• Name and address of the supplier of service
• Date(s) of service for which the initial determination was issued (dates must be reported in a manner consistent with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form)
• Which service(s) is at issue in the redetermination
• Name of appellant
• Signature of the appellant

The redetermination must be requested within 120 days of the initial determination date. The initial determination date is the date on the Medicare Remittance Notice (MRN) or the beneficiary's Medicare Summary Notice (MSN). When the filing deadline for a redetermination ends on a Saturday, Sunday, legal holiday, or any other nonwork day, the contractor shall apply a rollover period that extends the filing deadline to the first working day after the Saturday, Sunday, legal holiday, or other nonwork day. For example, if the filing deadline for a redetermination falls on the Saturday before Columbus Day, the filing deadline is extended to the first working day after the Columbus Day holiday. Redetermination requests made after the 120-day time limit should include an explanation regarding the late filing. For information about when good cause may apply for a late filing, see Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 29 .

The redetermination will be conducted within 60 days of receipt. Unprocessable claims, those with message MA130  ("Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.") must be corrected and resubmitted, rather than submitting a redetermination or reopening request.

The redetermination department thoroughly rechecks the claim, previously submitted documentation, and any new information the inquirer provides. Upon completion of the redetermination, if additional coverage can be allowed, the claim(s) will be adjusted and additional monies will be issued.

If the determination is a full reversal, the MRN and MSN are notification of the redetermination decision.

If the determination is a partial reversal, then the MRN and MSN are sent and a letter is written to the appellant or representative explaining the redetermination decision and further appeal rights. All parties to the appeal are copied on the redetermination decision. An adjustment is also done with additional monies issued.

If the reviewer finds no additional coverage can be allowed, a letter is written to the appellant or representative explaining the redetermination decision and further appeal rights. All parties to the appeal are copied on the redetermination decision.

Reminders

• Illegible Documentation
  • If the medical notes are handwritten and illegible, the appeal will remain denied as there is no medical documentation to review. If some of the medical documentation submitted is illegible, that documentation will be excluded and only the legible pieces will be considered as part of the appeals process.
• Signatures
  • All redetermination requests received without the appellant's signature are dismissed as incomplete requests
• Documentation
  • Include 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

Overpayment Redetermination Request

• On Redetermination form, mark overpayment box to alert Noridian staff that this is an appeal for an overpayment
• Include copy of overpayment letter
• Noridian has a specific Post Office Box for DME Overpayment Redeterminations.

Written Requests for Redeterminations Filed on Behalf of the Beneficiary

A written request for redetermination may be submitted by someone other than the beneficiary or an appointed representative on behalf of a beneficiary. An appointment of representative form is not needed if the request for redetermination clearly shows the beneficiary knew of or approved the submission of the request for redetermination (e.g., the request is submitted with the beneficiary's MSN or with a written authorization from the beneficiary). People who often act on behalf of a beneficiary in filing a redetermination request include, but are not limited to: the spouse, parent, daughter or son, sister or brother, or neighbor/friend.

Beneficiary advocacy groups, suppliers, doctors, and Members of Congress may also submit a request for redetermination on behalf of a beneficiary. These requests will be accepted if the request for redetermination clearly shows the beneficiary knew of or approved the submission. In absence of the beneficiary's clear knowledge or approval, an appointment of representative form or written statement is required.

Email Redeterminations

Questions and concerns regarding redeterminations may be emailed to dmeredeterminations@noridian.com

• 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
• Policies

Confidential information cannot be e-mailed. This includes Protected Health Information (PHI), such as patient names, claim information, Health Insurance Claim (HIC) numbers, Social Security numbers, Claim Control numbers (CCNs) or supplier numbers. This type of information cannot be e-mailed because it may be possible for others to view the contents.

This e-mail option is for suppliers only and is not to be used by beneficiaries.