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Printed Date: 9/22/2015
The purpose of the first level appeal decision letter, also known as the Medicare Redetermination Notice (MRN), is to notify the provider of the decision on their Medicare appeal. The decision can be:
If a provider disagrees with the first level appeal decision, the letter instructs the provider to:
Note: If the provider agrees with the decision, no action will need to be taken.
The letter is broken into sections of information for the provider concerning their first level appeal.
Summary of Facts:
Decision: A brief statement of the appeal decision.
Explanation of the Decision: Explanation of what policy (Local Coverage Determination (LCD), National Coverage Determination (NCD)), regulations and/or laws were used to make the determination.
Who is Responsible for the Bill? Information concerning the limitation of liability, waiver of recovery and physician/supplier refund requirements are included, as applicable.
What to Include in Your Request for an Independent Appeal: If the denial was based on insufficient documentation, or if specific types of documentation are required to issue a favorable decision, the list of what documentation would be necessary to pay the claim is listed here.
Important Information about Your Appeal Rights:
Resources for Medicare Enrollees:
Reconsideration Request Form: The form providers should use if they wish to appeal the first level appeal decision to the QIC.
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Last Updated: 03/27/2019