Medicare first level appeal - Redetermination.

A re-determination is the first level of an appeal after the initial determination has been made on a
claim. This is a second look at a claim and any supporting documentation. The time frame for
submitting a request for a redetermination is 120 days from the date on denial on your remittance
notice. If an initial determination has not been made on a claim, there are no appeal rights
available. For example, a claim that has been rejected because information was missing has no
appeal rights.

All redetermination requests must be made in writing. Prior to 2006, some redeterminations
could be handled over the telephone, but that process has been eliminated. Be sure to mail
appeals to the appropriate address. Requests sent to the incorrect address will delay processing
time.

Medicare Redetermination
P.O. Box 1000
Hingham, MA 02044-1000

How do I submit a request?
Each written Redetermination request must include all of the following:

• Beneficiary name
• Medicare Health Insurance Claim number
• Name and address of provider
• Date of Service for which the initial determination was issued (in a manner that complies
with the Medicare claims filing instructions)
• Identification of the reason of the appeal
• Signature of the requestor

Many requests are dismissed because one or more of these items are missing from the request.
To avoid a dismissal of this type, we strongly recommend the use of the Medicare
Redetermination Request Form, CMS 20027.This form is available on the CMS website at
http://www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf

Time Limit
A request for a Redetermination must be received by the Medicare contractor within 120 days
from the date of the initial determination. (The date will appear in the top right-hand corner of
the remittance advice.)

How will I be notified of the decision?

NHIC will mail a fully favorable decision, as well as all unfavorable decisions within 60 days of
receipt. A decision is fully favorable when Medicare approved amount minus any cost sharing
provisions (insurance, deductibles, etc.) has been found payable. In the past, for fully favorable
decisions, parties were notified only through the Medicare Summary Notice and Remittance
Advice. If the decision is overturned, NHIC will send a brief written notification to the appellant
informing them that the redetermination is favorable and that an MSN and/or RA will follow.