First Level of Appeal: Redetermination by a Medicare Contractor

Any party to the initial claim determination that is dissatisfied with the decision may request a redetermination. A redetermination is a review of the claim by Medicare Administrative Contractor (MAC) personnel not involved in the initial claim determination.

Requesting a Redetermination

An initial determination decision is communicated on the beneficiary's Medicare Summary Notice (MSN), and on the provider's, physician's and supplier's Remittance Advice (RA). The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file a redetermination request. The notice of initial determination is presumed to be received 5 calendar days after the date of the notice, unless there is evidence to the contrary. 

A redetermination must be requested in writing. There are 2 ways that a party can request a redetermination:

  1. Fill out the form CMS-20027 (available in “Downloads” below).
  2. Make a written request containing all of the following information:
    • Beneficiary name
    • Medicare number
    • Specific service(s) and/or item(s) for which a redetermination is being requested
    • Specific date(s) of service
    • Name of the party, or the representative of the party
    • An explanation of why the appellant disagrees with the contractor's determination

The appellant should include with their redetermination request any and all documentation that supports their argument against the previous decision. A minimum monetary threshold on the claim is not required to request a redetermination. The redetermination request must be sent to the MAC that made the initial claim determination (this information is on the MSN and the RA). Check the MAC website for more information on how to file appeals. Most MACs allow electronic submission of appeals through their website. The contact information for each MAC can be found using the following link: /Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs#MapsandLists .

Note: MACs do not process claim corrections involving minor errors and omissions through the appeals process. For information on how to request correction of minor errors and omissions, see the Medicare Learning Network (MLN) Matters Reopening article in the "Downloads" section below, or refer to the Medicare Claims Processing Manual IOM 100-4 Chapter 34 Reopening and Revision of Claim Determinations and Decisions (PDF).

Dismissal of a Redetermination Request

A MAC may dismiss a request for a redetermination for various reasons, some of which may be:

  1. If the party (or appointed representative) requests to withdraw the appeal
  2. If there are certain defects, such as
    1. The party fails to file the request within the appropriate timeframe and did not show (or the MAC did not determine) good cause for late filing
    2. The representative is not appointed properly
    3. The requestor is not a proper party

Detailed information on MAC dismissals can be found in the Medicare Claims Processing Manual IOM 100-4 Chapter 29 Appeals of Claims Decisions (PDF).

Parties to MAC dismissals have 2 options to dispute the dismissal:

  1. Request that the Qualified Independent Contractor (QIC) review the dismissal
  2. Request that the MAC vacate the dismissal

 

Request QIC Review of the Dismissal

Request MAC to Vacate the Dismissal

Filing Timeframe

60 days after dismissal receipt

6 months after date of dismissal notice

Review Criteria

Is dismissal correct?

Is there good and sufficient cause for dismissal?

Course of Action

Vacate dismissal and remand case to MAC for redetermination

Vacate dismissal and issue redetermination decision

Subject to Further Review?

NO

NO 

 

NOTE: A QIC’s review of a contractor’s dismissal of a redetermination request is binding and not subject to any further review - see 42 CFR 405.974(b)(3). 

Redetermination Decision Notification

Generally, the MAC will send its decision (either in a letter, an RA, and/or an MSN) to all parties within 60 days of receipt of the request for redetermination. The decision will contain detailed information on further appeals rights, where applicable.

Fact Sheet: Redetermination Appeals Data

These reports summarize and highlight some of the key data on redeterminations from January 1, 2011 through December 31, 2018.  To view the Appeals Fact Sheets, click on the link in the "Downloads" section below.

Page Last Modified:
11/15/2019 06:36 PM