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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 
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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
    • Valid signatures must still be legible, contain at least the entire first name and may not be reduced to initials
  • 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
  • If you have received a Redetermination decision regarding this issue; you must request a Reconsideration from QIC

Appeal Demand Letters

Received a Demand Letter due to an identified overpayment? Want to submit a Redetermination request but not sure how? See the Appealing Demand Letters webpage for details.
 

Last Updated Aug 14, 2017