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Linda Collins Blogger

Medicare Appeals Process – Level 1: Redetermination

Posted by Linda Collins | April 19, 2016

You submit a claim to Medicare and receive a denial. Regardless of the auditor, (MAC, CERT, RAC) you have the right to appeal Medicare coverage and payment decisions. Each level of appeal requires specific forms, information, and timelines to be met. The first level of appeal is a redetermination.

Prior to filing an appeal, be sure to understand the exact reason for denial. Many denials have generic reasons such as "lack of medical necessity." Use the provider portals available on the MAC websites to obtain more information.

NHIC, Region A: http://www.medicarenhic.com/dme/psphome.aspx

NGS, Region B: https://connex.ngsmedicare.com/home/start.swe?SWECmd=Start&SWEHo=connex.ngsmedicare.com

CGS, Region C: https://www.cgsmedicare.com/medicare_dynamic/jc/denials.asp

Noridian, Region D: https://med.noridianmedicare.com/web/jddme/topics/portal

Accessing the claims information through online tools will allow you to see the reason for the denial along with specific information about the claim. This information may be helpful to you as you prepare for appeals. Be sure to have the 14-digit CCN (customer care number, found on the claim or EOB) when you sign on to the site.

Once you have the denial information, it is time to file a redetermination. When a claim is denied, the MAC will provide information on the redetermination process in the denial letter. A request for a redetermination must be filed either on Form CMS-20027 or in written form with the following information provided:

  • 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

​Take the time to organize your documents, identify each as a specific exhibit, create a table of contents, and a short cover letter justifying the appeal.

Medicare gives you 120 days to file your redetermination (i.e., first-level appeal). But if you simply notify the MAC within 30 days of the date of the demand letter that you intend to appeal, you can avoid Medicare automatically recouping the amounts at issue. If you fail to provide this notice within 30 days – your request must be date-stamped and in the MAC's mailroom within 30 days of the date on the demand letter – Medicare will recoup the overpayment by offsetting against current claims you're filing.

The MAC will usually respond to the appeal within 60 days of receipt of written notice.

If your redetermination is denied, you will follow the steps to submit a second level appeal. This level is a reconsideration and will be discussed in the next R&R post.

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