Redetermination - JF Part A

A Redetermination is the first level of an appeal and is a request to review a claim when there is a dissatisfaction with the original determination. It is an independent re-examination of an initial claim determination.

Access the below Redetermination related information from this page.

• Determine if a Claim has Appeal Rights - Decision Tree
• Redetermination Request Options
• Changes/Inquires Not Accepted as a Redetermination Request
• Requests Filed on Resubmitted Claims
• Add, Remove or Change Lines
• Overpayment Redetermination Request
• Good Cause for Extension

Redetermination Request Options

• Electronic Submission
  • Submit via 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
  • 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

Changes/Inquires Not Accepted as a Redetermination Request

• 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 provider received a Redetermination decision regarding this issue; must request a Reconsideration from QIC

Requests Filed on Resubmitted Claims

For appeals of a specific line item or service, the date of the first MSN or RA that states the coverage and payment decision is the date of the initial determination. Adjustments to the initial claim or claim resubmissions for the same item/service on the same date of service that are included on subsequent MSNs or RAs, but do not revise the initial determination, do not extend/change the appeal rights on the initial determination. Read more within CMS Internet Only Manual (IOM), Publication 100-04, Chapter 29, Section 310.4, C3.

Example

• A claim* is submitted and denied, then resubmitted and processed. A redetermination request is submitted appealing the newest claim. In this example, because both claims are for the same service, the Medicare Administrative Contractor (MAC) would review the oldest valid claim. This claim would also be used in determining late file.

*Claim - Document Control Number (DCN) or Internal Control Number (ICN)

Add, Remove or Change Lines

Requests to add charges, remove and/or change paid lines on a submitted claim should NOT be submitted on a Redetermination Request Form. These requests should be completed through the Electronic Data Interchange (EDI) system, Direct Data Entry (DDE), or by mailing additional charges on a new original red and white UB-04 form. To adjust a claim, use the appropriate type of bill (TOB) (XX7), Document Control Number (DCN) of the claim being adjusted, proper condition code, adjustment reason code and detailed explanatory remarks in Form Locator 80 or the electronic equivalent.

Overpayment Redetermination Request

• View the Limitation on Recoupment webpage for information regarding Section 1893(f)(2)(a) of the Social Security Act, which provides limitations on the recoupment of Medicare overpayments during the appeals process

Good Cause for Extension

Requests made after the 120-day time limit must include an explanation regarding the late file.

• Good cause may apply for a late filing, see CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Publication, Chapter 29 as it addresses the issue of good cause for extension of the time limit for filing appeals. If good cause is not found, request will be dismissed