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Level 1: Redetermination 

Redetermination Form

CMS 20027

Filing the Redetermination

A party dissatisfied with an initial determination may request that the MAC review its determination. A redetermination is the first level of appeal after the initial determination on Part A and Part B claims. It is a second look at the claim and supporting documentation and is made by an employee that did not take part in the initial determination.

Time Limit for Filing a Request for Redetermination

A party must file a redetermination request within 120 days of the date of receipt of the notice of initial determination (MSN or RA) with the contractor indicated on the notice of initial determination (receipt of the notice of initial determination is presumed to be 5 days after the date of the MSN or RA unless there is evidence to the contrary). The date of filing for requests filed in writing is defined as the date received by the appropriate contractor in the corporate mailroom, the date received via facsimile, or the date received in the secure Internet portal/application. If the party has filed the request in person with the contractor, the filing date is the date of filing at such office, as evidenced by the receiving office’s date stamp on the request. If the party has mailed or filed in person the request for redetermination to a CMS, SSA, RRB office, or another contractor or Government agency within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired, the contractor shall consider the date the request was first filed with a contractor or an official Federal government entity as the date of receipt for purposes of determining if the redetermination request was filed in a timely manner.

Filing a Request for Redetermination

A request for redetermination must be filed with the contractor in writing. The request may be made by a party to the appeal and/or the party’s representative. Appeal requests submitted electronically via a facsimile or secure Internet portal/application shall be considered to have been received in writing.

Written Requests for Redetermination Made by Beneficiaries

Beneficiaries may request a redetermination by submitting a signed copy of their MSN, by filing a completed Form CMS-20027 or by submitting a signed letter that indicates dissatisfaction with a claim determination. As noted above, appeal requests received via a facsimile or secure Internet portal/application shall also be considered received in writing. Requests for redetermination may be submitted in situations where beneficiaries assume that they will receive a redetermination by questioning a payment detail of the determination or by sending additional information back with the MSN, but don’t actually say: I want a review. For example, a written inquiry stating, “Why did you only pay $10.00?” is considered a request for redetermination. Common examples of phrasing in letters from beneficiaries that constitute requests for redetermination include, but are not limited to the following:

    • “Please reconsider my claim.”
    • “I am not satisfied with the amount paid - please look at it again.”
    • “My neighbor got paid for the same kind of claim. My claim should be paid too.”

The request may contain the word appeal or review. There may be instances in which the word review is used but where the clear intent of the request is for a status report. This should be considered an inquiry.

Written Requests for Redetermination Submitted by a State, Provider, Physician or Other Supplier

States, providers, physicians, or other suppliers with appeal rights must submit written requests via mail, facsimile or secure Internet portal/application (if the contractor chooses to receive requests via facsimile or CMS approved secure Internet portal/application) indicating what they are appealing and why. A redetermination request may be submitted using:

A completed Form CMS-20027 constitutes a request for redetermination. The contractor supplies these forms upon request by an appellant. “Completed” means that all applicable spaces are filled out and all necessary attachments are included with the request. The form can be found on the CMS Web site at: http://www.cms.gov/cmsforms/downloads/cms20027.pdf

A written request/letter. At a minimum, the request shall contain the following information:

    • Beneficiary name;
    • Medicare health insurance claim (HIC) number;
    • The specific service(s) and/or item(s) for which the redetermination is being requested;
    • The specific date(s) of the service; and
    • The name and signature of the party or the representative of the party.

Frequently, a party will write to a contractor concerning the initial determination instead of filing Form CMS-20027. How to handle such letters depends upon their content and/or wording. A letter serves as a request for redetermination if it contains the information listed above and either: (1) explicitly asks the contractor to take further action, or (2) indicates dissatisfaction with the contractor’s decision. The contractor counts the receipt and processing of the letter as an appeal only if it treats it as a request for redetermination.

NOTE: The details of its actions must be detailed (e.g., when action was taken and what was done) for possible subsequent evidentiary and administrative purposes.

A secure Internet portal/application. If a contractor has received CMS approval for the use of a secure Internet portal/application to support appeals activities, appellants may (but are not required to) submit redetermination requests via the secure Internet portal/application. Written requests submitted via the portal/application shall include the required elements for a valid appeal request.

Requirements for a Valid Signature on an Appeal Request

For appeal purposes, the only acceptable method of documenting the appellant’s signature on the appeal request is by written, digital, digitized, or electronic signature as discussed below:

    • A written signature may be received via hard copy mailed correspondence or as part of an appeal request submitted via facsimile.
    • An electronic, digital, and/or digitized signature is an acceptable signature on a request submitted via a CMS-approved secure Internet portal/application. The secure Internet portal/application shall include a date, timestamp, and statement regarding the responsibility and authorship related to the electronic, digital, and/or digitized signature within the record. At a minimum, this shall include a statement indicating that the document submitted was, “electronically signed by” or “verified/approved by” etc.
    • A stamp signature or other indication that a “signature is on file” on the CMS 20027 form or other documentation (such as a blank claim form) submitted to support the appeal request shall not be considered an acceptable/valid signature regardless of whether the appeal request is submitted via hard copy mail or via facsimile.

The Redetermination Process

Timely Processing Requirements

The contractor must complete and mail a redetermination notice for all requests for redetermination within sixty (60) days of receipt of the request.  The date of receipt for purposes of this standard is defined as the date the request for redetermination is received in the corporate mailroom or the date when the electronic request for appeal is received via facsimile or through the secure Internet portal/application. For misfiled redetermination requests, the proper contractor jurisdiction must complete and mail a redetermination notice within sixty (60) days of receiving the misfiled request in their corporate mailroom.

Conducting the Redetermination

    • The redetermination is an independent review of an initial determination. The individual performing the redetermination must not be the same person who made the initial determination.
    • The contractor reviews the evidence and findings upon which the initial determination was based, and any additional evidence the parties submit or the contractor obtains on its own.
    • The contractor may raise and develop new issues that are relevant to the claims in the redetermination.
    • There may be times where the appellant requests a redetermination of an entire claim and there may be times where he/she requests a redetermination of a specific line item on the claim. The contractor should review all aspects of the claim or line item necessary to respond to the appellant’s issue. For example, if the appellant questions the amount paid, the contractor must also review medical necessity, coverage, deductible, and limitation on liability, if applicable.
    • If the appellant requests a redetermination of a specific line item, the contractor reviews all aspects of the claim related to that line item. If appropriate, it reviews the entire claim. If it reviews more than what the appellant indicated, it includes an explanation in the rationale portion of the redetermination letter of why the other service(s)/item(s) were reviewed.

Requests for Documentation

Requesting Documentation for State-Initiated Appeals

The reviewer should not request documentation directly from a provider or supplier for a State- initiated appeal. If additional documentation is needed, the reviewer should request that the submitter of the appeal (i.e., the State or the party authorized to act on behalf of the Medicaid State Agency) obtain and submit necessary documentation. The requested documents may be submitted via facsimile or via a secure Internet portal/application. Documentation previously submitted by the State or the provider/supplier as part of a demand bill review must be included in the appeals case file for review during the redetermination.

Requesting Documentation for Provider or Supplier -Initiated Appeals

For provider and supplier initiated appeals, when necessary documentation has not been submitted, the reviewer advises the provider or supplier to submit the required documentation. The reviewer notifies the provider or supplier of the timeframe the provider or supplier has to submit the documentation. The reviewer documents his/her request in the redetermination case file. The requested documents may be submitted via facsimile and/or via a secure Internet portal/application. In some situations, a provider or supplier may inform the reviewer that it is having trouble obtaining supporting documentation from another provider or supplier (e.g., an ambulance supplier who is requested to submit hospital admission records). In this situation, the contractor may assist the provider or supplier in obtaining records. If the additional documentation that was requested is not received within fourteen (14) calendar days from the date of request, the reviewer conducts the redetermination based on the information in the file. The reviewer must consider evidence that is received after the fourteen (14) day deadline but before having made and issued the redetermination.

Requesting Documentation for Beneficiary-Initiated Appeals

For beneficiary initiated appeals, when necessary documentation has not been submitted, the reviewer advises the provider or supplier to submit the required documentation. The reviewer notifies the beneficiary (either in writing or via a telephone call) when the reviewer has asked the beneficiary’s provider or supplier for additional documentation. The reviewer also notifies the beneficiary that the provider or supplier has fourteen (14) calendar days to submit the additional documentation that has been requested, and that if the documentation is not submitted, the reviewer will decide based on the evidence in the case file. If the reviewer sends the beneficiary a letter, it must include a description of the documentation that has been requested.

Extension for Receipt of Additional Documentation

Contractors shall educate parties to include all supporting documentation with the redetermination requests submitted via mail, facsimile or a secure Internet portal/application. However, when a party submits additional evidence (via mail, facsimile or a secure Internet portal/application) after filing the request for redetermination, the contractor’s sixty (60) day decision- making timeframe is automatically extended for up to fourteen (14) calendar days for each submission. This additional time is allowed for all documentation submitted by a party after the request, even when the documentation was requested by the contractor. Although this extension is granted to the contractor for making decisions, it should not routinely be applied unless extra time is needed to consider the additional documentation.

The Redetermination Decision

The law requires contractors to conclude and mail and/or otherwise transmit the redetermination decision within 60 days of receipt of the appellant's request. For unfavorable redeterminations, the contractor mails the decision letter to the appellant, and mails copies to each party to the initial determination (or the party’s authorized representative and/or appointed representative, if applicable).

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