Redeterminations: What information should I send with the request?
A redetermination is the first of five appeal levels available for providers to contest initial claim determinations. There is no minimum controversy amount, but you must file a request within 120 days from the initial claim determination date in order to meet the timeliness requirement. Redetermination Requests that are not filed timely cannot be considered unless documentation is submitted to explain why the appeal was filed late.
Before you determine the need for a request, please check your submission information for accuracy, then prepare your documentation. As you select the supporting documentation for your request, keep the following information in mind:
- CMS requires contractors to consider all policies and procedures applicable to the claim facts
- Please ensure that you attach documentation to support the 'complete' questioned service and all services on your claim. For example, a global procedure request should include documentation to support all services provided during the global period in addition to the other services listed on the claim. If you only submit the documentation for one service, you may not obtain your desired results.
Note: Claims rejected as unprocessable (billing errors, usually indicated with remark code MA130) have no appeal rights and should not be submitted as Redetermination Requests. Make the appropriate claim correction and resubmit the claim.
To ensure you receive a successful decision, review the three key items listed below:
- Requests submitted without all claim services documentation may result in an unfavorable decision for the provider
- All applicable claim lines and claim details are reviewed for medical necessity, correct coding, and supportive documentation
- Additional claims pertaining to the questioned service are subject to review and possible adjustment
- You can reduce the number of claims you appeal by ensuring that you submit all appropriate documentation, including applicable modifiers and ICD-9 codes, with the initial claim. Be sure that your documentation supports the information you are submitting.
You may obtain forms and review additional detailed information regarding the appeals process and filing criteria on our Web site. Use these shortcuts to access appeals information quickly and easily:
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