Redetermination by Medicare Contractors
A redetermination is an examination of a claim by Medicare contractor personnel who are different from the personnel who made the initial determination.
CMS contracts with private insurance companies ("carriers" for Part B and "fiscal intermediaries" (FIs) for Part A) to perform many processing functions on behalf of Medicare, including local claims processing and the first-level appeals adjudication.
The individual filing the appeal (the “appellant”) has 120 days from the date of receipt of the initial claim determination to file an appeal.
There is no minimum dollar threshold to meet before requesting a redetermination.
Request a Redetermination
Within 120 days from receipt of notice of inital determiniation (Remittance Advice or "RA"). Notice of initial determination is presumed to be received 5 days from the date of the notice unless evidence to the contrary
Submit a completed Form CMS-20027 or
Submit a written request, including:
- Beneficiary name
- Medicare Health Insurance Claim (HIC) number
- Specific service and/or item(s) for which a redetermination is being requested
- Specific date(s) of service
- Name and signature of the party or the authorized or appointed representative
NOTE: Minor errors and omissions on claims are no longer corrected through the appeals process.
See: Reopenings, MLN Matters MM 4147, September 2006
The appellant should attach any supporting documentation to the redetermination request.
Contractors will generally issue a written Medicare Redetermination Notice (MRN) within 60 days of receipt of the redetermination request.
Any party to the redetermination dissatisfied with the decision has 180 days to request a reconsideration (second-level appeal).
- The MRN must contain explanation of how CMS policies apply to the case and an explanation of how to request a reconsideration.
Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) enacted numerous contracting reforms that can impact the claims audit and appeals processes. Check often for new developments: Medicare Contracting Reform Updates