Redeterminations: What Information Should I Send with Faxed, Online, or Mailed Requests
A redetermination is the first of five appeal levels available for providers to contest initial claim determinations. You can file a redetermination request with Railroad Medicare through our free internet portal, eServices, by fax at (803) 462-2118, or via the esMD mechanism, but with whichever method you choose, you must include documentation to support your appeal.
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 with remark code MA130 have no appeal rights and should not be submitted as redetermination requests. Please make the appropriate claim correction and resubmit the claim.
Appeals for Multiple Claims Involving the Same Issue
If multiple claims involve the same issue, it is not necessary to submit each appeal separately. You may file a single appeal for multiple claims. If multiple claims involve the same issue, you may submit one appeal request with all claims included. All appeal requests must be submitted in writing. Each claim in a multiple request must be clearly identified in some manner to allow identification of:
- The beneficiary Medicare number
- The specific service or item for which the redetermination is being requested (copies of the Remittance Advice or a spreadsheet is acceptable)
- The specific dates of service
To ensure you receive a successful decision on single or multiple appeal requests, review the five key items listed below:
- Requests submitted without all appropriate signed documentation might result in an unfavorable decision
- 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 may reduce the number of claims you appeal by submitting all appropriate documentation, including applicable modifiers and diagnosis codes, with the initial claim. Be sure that your medical record documentation supports the information you are submitting.
- All requests must contain the name of the person requesting the appeal. Redetermination requests received prior to July 8, 2019, also required the signature of the person requesting the appeal.
Note: All redeterminations must be received within 120 days from the date of receipt of the initial determination. The receipt of the initial determination is presumed to be five days from the date of the notice.
Once the redetermination request is completed, Railroad Medicare will provide a written response. The response will depend upon Railroad Medicare’s decision:
- If it is determined the original decision on the claim can be changed and payment is due, a new remittance notice and a payment will be issued
- If the original decision on the claim is upheld, a detailed letter will be sent explaining why additional payment cannot be allowed
- If the original decision on the claim is changed but no further payment is due, a detailed letter will be sent explaining the reasons why no payment is forthcoming
- If it is determined a portion of the claim can be allowed, a payment and a corrected remittance notice will be issued for the services allowed. A separate, detailed letter will be sent explaining the adjustment and explaining why additional payment cannot be allowed on the other services.
Railroad Medicare Redetermination forms are available on our forms page. Only one form is needed for a 'multiple appeal' request. For a 'multiple appeal' request, complete the form using the information for the first claim in question. In the Reason for Request box, indicate 'multiple request' along with the reason for the appeal.
- CMS Publication 100-04 (PDF), Chapter 29