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Sunday, June 6, 2010

Medicare claim 1st level appeal - Redetermination

This is the first level of appeal after the Medicare contractor (fiscal intermediary, carrier, or Medicare Administrative contractor) offers an unfavorable initial determination. Providers have 120 days from the date the initial determination was received to file an appeal (CMS assumes it will take five days to receive U.S. mail). You can file the appeal on the CMS 20027 form, or if you are not able to fill out this form, CMS requires the following patient identifying information to accompany the request:

• The beneficiary’s name
• Medicare health insurance number
• Specific item or services for which the redetermination is being requested
• Dates of service
• The name and signature of the beneficiary

Consequently, it is critical that you submit the request and supporting documentation simultaneously to avoid
an automatic 14-day extension of the contractor’s decision. The contractor has 60 days from the date of the receipt ofthe appeal to reverse or uphold its initial determination. The contractor will use the remittance advice notice (RA) and Medicare Summary Notice (MSN) to notify the provider and beneficiary of its decision and will disclose the coverage rationale used to make its decision, the clinical evidence used, and notice of the
opportunity to appeal at a higher level. If you are unable to meet the filing deadline, the contractor has the right to dismiss the appeal. To circumvent this, you will need to show (in writing) “good cause” explaining extenuating circumstances that led to the tardy submission. This should be accomplished within
six months of receiving the dismissal notice from the contractor. Conditions to establish good cause include (but are not limited to):

• Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the contractor, or the Social Security Administration) to the provider, physician, or other supplier; or,

• Unavoidable circumstances that prevented the provider, physician, or other supplier from timely filing a
request for redetermination. Unavoidable circumstances encompass situations that are beyond the provider,
physician, or supplier’s control, such as major floods, fires, tornados, and other natural catastrophes.

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