First Level of Appeal: Redetermination by a Medicare Contractor
A redetermination is an examination of a claim by the fiscal intermediary (FI), carrier, or Medicare Administrative Contractor (MAC) personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.
Requesting a Redetermination in Writing
A request for a redetermination must be filed either on Form CMS-20027 or on a written request that includes all of the elements listed below. To link to this form, scroll down to "Downloads".
- 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
- Signature of the party or the authorized or appointed representative of the party
The redetermination request must be sent to the FI, carrier or MAC that made the initial claim determination (this information is on the beneficiary's Medicare Summary Notice (MSN) or the provider's Remittance Advice (RA)). If you do not have the MSN or RA, you can locate the FI, carrier or MAC information through the following link: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html
The appellant should attach any supporting documentation to their redetermination request. The FI, carrier, or MAC will generally issue a decision (either in a letter, a revised remittance advice, or a Medicare Summary Notice) within 60 days of receipt of the redetermination request.
Note: FIs, carriers, and MACs can no longer correct minor errors and omissions on claims through the appeals process. For information on how to correct minor errors and omissions, please refer to the Medicare Learning Network (MLN) Matters article in the "Downloads" section below.
Fact Sheet: Redetermination Appeals Data
These reports summarize and highlight some of the key data on redeterminations from January 1, 2008 through December 31, 2012. To view the Fact Sheets, click on the link in the "Downloads" section below.
- Page last Modified: 02/28/2014 8:11 AM
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