What is the Medicare redetermination process for Medicare?

For Original Medicare plans, the first level of every appeals process is redetermination. This level of appeal involves a re-examination of your original claim by the same company or entity that processed your original claim, but with different personnel. If you’re appealing a Medicare Plan other than Original Medicare, then your appeals process may differ.

Original Medicare appeals must be requested within 120 days of the date you receive your Medicare Summary Notice (MSN). It is occasionally possible to file after 120 days if you provide Medicare with a reason you filed late. There is not a minimum monetary threshold at the first level of appeal, so you can ask for a redetermination no matter how low cost your medical claim. The request for redetermination at this level must be filed by you, your representative, or even your health care provider. This can be done in one of three ways.

Fill out the “Redetermination Request Form”

The first and easiest way to make an appeal is to fill out a “Redetermination Request Form”and send it to the address listed on your MSN. This simple, one-page form is available on Medicare.gov. It includes basic information about what you are appealing for, why, and what evidence you have to support your claim. One example of good evidence is submitting documents demonstrating an item or service is medically necessary. Though you do not have to submit evidence, it could increase the likelihood of your redetermination being successful. You can even choose to submit your evidence after submitting your redetermination request form. To do this you need to attach a statement describing the type of evidence you are going to submit, and when you’re going to submit it. You can submit some evidence with the form and additional evidence later, if needed. However, both the form and all the evidence must be in before your redetermination notice is issued. This is usually 60 days, but if you submit additional evidence the decision can take up to 14 extra days.

Appeal through your Medicare Summary Notice (MSN)

A second way to make a redetermination appeal is through your Medicare Summary Notice (MSN). On the last page of the MSN there are instructions on how to do this. Generally, you circle the items/services you want redetermined on the MSN, and provide an attached, written explanation why you circled them. As with the redetermination form, you are encouraged to provide evidence to support your argument for coverage. Your Medicare number should be on all the documents you submit. Finally, you include your contact information and signature (and the signature of your representative if applicable) and mail it off. The address you send your MSN to is listed in the “Appeals Information” section of the MSN.

Appeal by letter

Finally, you can send a letter to the company that handles Medicare claims in the “Appeals Information” section of the MSN. As with the other methods, you must detail exactly what services you are appealing (including dates), why, and provide appropriate evidence to back up your argument. You will also need your name, Medicare number, contact information, and signature.

After you receive your “Medicare Redetermination Notice,” you have 180 days to request reconsideration by a Qualified Independent Contractor. This will continue your appeal.

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