Redetermination Time Limit: Reminder

It is critical that you submit requests for redetermination within the time limits established by the Centers for Medicare & Medicaid Services. These time limits can only be extended in certain circumstances.

Redetermination requests must be submitted within 120 calendar days from the date of receipt of on the initial determination notice. The initial determination notice is the Electronic Remittance Advice (ERA) or Standard Provider Remittance Notice (SPR):

  • From the first submission of that service
  • Does not include any service rejected as a billing error (remark code MA130)
  • If the date shown on your ERA or SPR is more than 120 days from the current calendar date, the time frame for requesting a redetermination has ended

Example:

Date of Initial Determination
(From the ERA or SPR)
Current Calendar DateElapsed DaysRedetermination RightsDate Redetermination must be received
05/15/2017 10/15/2017 153 No 09/17/2017
08/15/2017 10/15/2017 61 Yes 12/18/2017

Note: CMS allows a grace period of an additional five days beyond the time limit of 120 days from the date of the initial notice. This allows for a 5-day period for mail delivery. We may allow for additional time if you can provide documentation that mail delivery took longer than five days.

Extension of Time Limit for Filing a Request for Redetermination
If an appeal request is filed late, the time period may be extended for filing a redetermination if you can demonstrate good cause. These extensions are not routinely granted, so it is important to provide supporting documentation if you are requesting an extension of this time limit.

References:

  • CMS Publication 100-04 (PDF, 840 KB), Chapter 29, § 240 
  • Use the Denial Resolution Tool to research denials. This tool provides resources that will help you submit the claim correctly and completely the first time. Access the tool right from the home page in the Self Service Tools section. 

Remember: Claims rejected as unprocessable (billing errors, indicated with remark code MA130) have no appeal rights and cannot be submitted as Redetermination requests. The best way to handle these errors is to correct and resubmit the claim.

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