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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 receipt date 60 days from receipt date Contractor Redetermination [PDF]

 

Providers may determine if a claim has appeal rights

Submit a Redetermination Request

Electronic Submission

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

Paper Submission

  • Access 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

Situations Claims Cannot be Appealed

  • 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
  • If you have received a Redetermination decision regarding this issue; you must request a Reconsideration from QIC

 

Last Updated Sep 06, 2017