Elements of a Redetermination Letter

A redetermination letter contains the following informational sections.

Opening

Explains what was reviewed, who provided the services and overview of the decision.

Summary of Facts

Provides specific details of the redetermination:

  • Document/Claim Control Number and dates of service requested
  • Type of service(s)
  • Initial determination date and
  • Statement with the initial determination
  • Date the request for the redetermination was received
  • List of all documentation submitted with the original redetermination

Decision

Provides the outcome and who is liable for the claim.

Explanation of Decision

Explains the logic and specific reasons used in making the decision:

  • Who reviewed the redetermination
  • What was reviewed
  • Decision made
  • Explanation of logic/reasons that led to decision
  • Explanation of coverage policy (Local Coverage Determination (LCD), National Coverage Determination (NCD)), regulations, policy guidance (CMS Internet Only Manual (IOM) provisions), and/or laws used to make determination

Determining Liability

Provides information on Limitation of Liability, waiver of recovery and provider 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).

Closing

Includes the examiner's name (first name and last initial) and Medicare Contractor.

 

Last Updated Feb 22, 2019