Regulations 42 CFR 405.807 provides that a party to an initial determination that is dissatisfied may request that the carrier review the determination. A redetermination is an independent reexamination of a claim. It is the first level of appeal. A request for redetermination must be filed within 120 days after the date of receipt of the determination notice.
For the JL (PA, NJ, MD, and DCMA, DE) and JH (AR, LA, CO, MS, NM, OK, TX), Indian health Services, and Veterans Affairs, effective August 13, 2012, requests for redeterminations can be filed in writing or via fax (1-888-541-3829). Mailing addresses are listed on the contact page section of the Appeal Center. Regulations dictate that requests for redeterminations may not be filed over the telephone.
CMS Publication 100-4, Medicare Claims Processing Manual, Chapter 29, section 310.1.B, clarifies the policy on appeals submitted by providers, suppliers, or Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations. It also revises the CMS policy by removing the requirement that the Medicaid State Agency, or its agent, secure written beneficiary authorization prior to it submitting an appeal request to CMS or its Medicare contractors.
All written appeal requests must contain the following information:
Medicare Beneficiary ID Number.
The specific service(s) and / or item(s) for which the redetermination is being requested.
The specific date(s) of the service.
A Medicare redetermination and clerical error reopening request form should be completed for each claim in question. CMS also has a redetermination request form available on their website.
Note: Please do not use this form for status of claims. The interactive voice response (IVR) should be utilized for all status inquiries (See the IVR link and click on Telephone Inquiry Quick Reference). This form should not be used for appeals for rejected claims (MSG’s CO-16 and/or MA130). Rejected claims are non-appealable and must be resubmitted with the corrected or missing information.
You may also send a written statement expressing disagreement with the initial determination and request that the claim in question be reviewed. This request must not only identify the initial determination with which the party is dissatisfied, but must also meet the requirements for the contents of an appeal request outlined above. CMS has clarified that contractors should not accept implied requests for reviews from providers, suppliers or states or the party authorized to act on behalf of the Medicaid State Agency. Incomplete forms or written requests that do not contain all of the necessary information will be dismissed by the contractor.
As stated in CMS Publication 100-4, Medicare Claims Processing Manual, Chapter 29, section 270.1, an individual appointed by a beneficiary or provider/supplier to act as the representative of the beneficiary / provider / supplier in conjunction with a claim(s) is known as an appointed representative. The beneficiary/provider / supplier has authorized their representative to make or give any request or notice; to present or to elicit evidence; to obtain information; and to receive any notice in connection with the claim or claims. This appointment must be accepted by the appointed individual to be valid.
Billing clerks or billing services employed by a physician or supplier to prepare and/or bill claims, process payment and pursue appeals act as an agent of the physician and do not need to be appointed as a representative.
Appointment of representative requirements are met if a completed CMS Form-1696 is submitted to the Medicare contractor. The form must be signed and dated by both the beneficiary/provider and the representative.
In order for us to consider all of the facts supporting your case, it is in your best interest to submit the appropriate supporting documentation for the patient's claim(s) in question. If supportive documentation is not submitted the redetermination will be conducted using information in our possession.
Contractors have also been instructed not to request documentation from a provider or supplier for a State-initiated appeal. If additional documentation is needed, contractors 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 within 120 days of the initial determination.
Please remember that providers / suppliers, Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency are responsible for submitting documentation, if any, that supports the contention that the initial determination was incorrect under Medicare coverage and payment policies. This documentation should be supplied with the appeal request or at the request of the contractor. Failure to submit requested documentation in a timely manner may result in processing delays.
Please make sure all copies of documentation includes the patient's name and are complete, legible, and contain both sides of each page, including page edges. Complete copies should include specific records to support the services on the claim(s) you are appealing and would include, as applicable, the following documents:
Physician progress notes
All lab reports
Diagnostic test results (regardless of where they are performed)
History and physical notes
Home health progress notes
Certificate of medical necessity
Skilled nursing facility records
Emergency room records
A specific process takes place when you withdraw an appeal request. Your request to withdraw must:
Be in writing.
Be submitted within 120 days from the date of this letter.
Include a sufficient reason explaining why the first review request was withdrawn and not pursued.
A letter documenting your decision to withdraw the appeal will be mailed to you. This letter explains the criteria that must be met if you wish to review the service(s) at another time.
Reference: CMS Publication 100-4, Claims Processing Manual, Chapters 29 & 34 and MLN article MM 4147 – Reopenings and revisions of claim determinations and decisions
Section 937 of the Medicare Modernization Act required CMS to establish a process, separate from appeals, whereby providers, physicians and suppliers could correct minor errors or omissions. CMS believes that it is neither cost efficient nor necessary for contractors to correct clerical errors through the appeal process.
CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor, such as:
Mathematical or computational mistakes;
Transposed procedure or diagnostic codes;
Inaccurate data entry;
Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate; or
Incorrect data items, such as provider number, use of a modifier or date of service.
Note that clerical errors or minor errors are limited to errors in form and content, and that omissions do not include failure to bill for certain items or services. A reopening shall not be granted to add items or services that were not previously billed. Third party payer errors do not constitute clerical errors.
Examples of issues that may not be handled as a clerical error reopening are as follows:
Limitation of liability issues;
Initial claim determinations issued as a result of the following:
Medical review denials
Comprehensive Error Rate Testing denials
Unified program integrity contactor UPIC) - Zone program integrity contractor (ZPIC)
Special medical review contractor (SMRC) denials (add this)
Prior authorization denials (add this)
MSP issues (Note: third party payer errors do not constitute clerical errors)
The addition of lines or items that were not previously billed;
The additional diagnosis / data does not permit payment of the claim
A Medicare redetermination and clerical error reopening request form should be completed for each claim in question.
Requests to correct clerical errors or add omitted data to finalized claims can be made easily by calling:
Providers: Delaware, Maryland, New Jersey, Pennsylvania, Washington, D.C.
JH Providers: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, IHS (Indian Health Service) / Tribal / Urban Indian Providers and Veterans Affairs Providers
Hours of operation are Monday through Friday between 8:00 a.m. and 4:00 p.m. ET.
Some examples of appropriate items for a telephone claim correction are:
Changes to the number of services or units
Diagnosis changes - Only primary DX
Add, change, or delete certain modifiers
Procedure code changes
Date of service changes
Referring doctor changes
History corrections - MUE vs Duplicate, Hospice, HMO and MSP
There are certain issues which cannot be resolved during the automated claim corrections via the IVR process:
Services requiring the review of medical documentation
Services involving limitation of liability
Place of service code
Retracting a claim
Deleting a claim/line item
Reporting billed in error
If the claim correction cannot be conducted via the IVR, the IVR will provide further instruction as to why the claim correction could not be accepted and a written appeal request will need to be submitted.
The IVR Claim Corrections Guide is located under the self-service tools section on our website.
You will need to provide the following information to perform a claim correction:
Internal control number
Date of service
A second level appeal is called reconsideration. Requests for reconsideration must be filed with a QIC. The name and address of the QIC will be specified in each redetermination notice. Reconsideration requests should be submitted in writing with a copy of the redetermination notice to the following address:
JL QIC: Delaware, Maryland, New Jersey, Pennsylvania, Washington, D.C.
C2C Innovative Solutions, Inc. -- QIC Part B North
P.O. Box 45208
Jacksonville, Florida 32232-5208
JH QIC: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, IHS (Indian Health Service) / Tribal / Urban Indian and Veterans Affairs Providers
C2C Innovative Solutions, Inc. - QIC Part B South
P.O. Box 45300
Jacksonville, Florida 32232-5300
A reconsideration request form should be used and will be provided with each redetermination notice issued. A reconsideration request form can also be downloaded from the forms section of our website. In lieu of the form, the reconsideration request must include the following items:
The beneficiary’s name;
Medicare Beneficiary ID Number;
The specific service(s) and items (s) for which the reconsideration is requested and the specific date(s) of service;
The name of the contractor that made the Redetermination.
A request for reconsideration must be filed within 180 days of the date of receipt of the notice of the redetermination. The date of filing for request filed in writing is defined as the date received by the QIC in their corporate mailroom.
In most cases, carriers are required to render a decision within 60 days for redeterminations and reconsiderations.
If you are dissatisfied with the reconsideration decision issued by the QIC, you may request a hearing by an ALJ by writing to the address provided in the QIC decision. Requests must be made within 60 days of receipt of the QIC decision.
The ALJ does not have the authority to overturn national coverage limitations made by the CMS. However, if the appeal involves an assigned claim and a medical necessity denial, the ALJ will determine whether the limitation of liability provision of the law was properly applied.
You may request an ALJ hearing by writing to the QIC at the address listed below or you may contact any Social Security Administration Office.
OMHA Centralized Docketing
200 Public Square, Suite 1260
Cleveland, OH 44114-2316
The claims value in dispute must meet the threshold for obtaining an ALJ hearing and a judicial review in Federal District Court. This is called the amount in controversy. The amount in controversy is recalculated and published on an annual basis, and is identified in your appeal notice of decision.
ALJ: The amount in controversy for ALJ hearing requests:
Made on or after January 1, 2020, is $170.00
Made on or after January 1, 2021, is $180.00
Departmental Appeals Board (DAB): None
Federal District Court Review: The amount in controversy for Federal District Court Review requests:
Made on or after January 1, 2020, is $1670.00
Made on or after January 1, 2021, is $1760.00
The amount in controversy is calculated in the following manner:
Amount charged minus Medicare payments already made or awarded = Subtotal balance
Subtotal balance minus any applicable deductible/coinsurance = Amount in controversy
$500 (amount charged) - $0 (Medicare payment made) = $500 (subtotal balance)
$500 (subtotal balance) -$100 (coinsurance) = $400 (balance)
$400 (balance) = $400 (amount in controversy)