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Redetermination

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.

Time Limit for Filing Request Time Limit to Complete Appellant's Request Where to File Form Filing Options
120 days from initial determination date or 120 days of initial overpayment 60 days from receipt date Contractor Redetermination [PDF]

 

Determine if a Claim has Appeal Rights

Submit a Redetermination Request

Electronic Submission

  • Submit via the NMP. It's fast, secure and economical
    • Access educational resources, learn how to register and view user manual on NMP webpage

Paper Submission

  • Access the Redetermination/Reopening Form - One request form per beneficiary and issue
  • Complete all form fields. An incomplete request is counted as a dismissal. View Redetermination/Reopening Form Tutorial for completion assistance
    • Accept electronic, typed, handwritten (must be in dark ink), scanned and digital and/or digitized signatures on the Redetermination Form
  • Send completed form and any applicable medical documentation (may include the Advance Beneficiary Notice of Noncoverage (ABN), office notes, operative reports, trip reports, etc) to appropriate address or fax number

Claims Cannot be Appealed in the Below Situations

  • Claim status/tracer questions, use Interactive Voice Response (IVR)
  • Medicare Secondary Payer (MSP) Inquiries
  • General Written Inquiries
  • Provider Address or Assignment changes, contact Provider Enrollment
  • Received a Redetermination decision regarding this issue? Request a Reconsideration from QIC

Appeal Demand Letters

When Medicare (Noridian) or other outside contract Comprehensive Error Rate Testing (CERT), Recover Auditor (RA), Zone Program Integrity (ZPIC) or the Supplemental Medical Review Contractor (SMRC) has determined that an overpayment has occurred, a Demand Letter is issued. Providers are given 30 days from the date of the Demand Letter to pay the requested overpayment amount. View the Appealing Demand Letters page for additional information on what documentation is needed when submitting a demand letter appeal and the different ways it can be submitted.

 

Last Updated Oct 18, 2017