Medicare Redetermination Form - Appealing And Reconsideration

By: Edward Neeman
Published: Thursday, September 27 2018
Last Updated: 4 years ago

If you are a patient who is unsatisfied with the decisions made by Medicare in regards to your treatment options, you may request a redetermination. The process of redetermination implies a review of the initial claim decisions by a Medicare Administrative Contractor who was not involved in the initial claim. Sometimes Medicare may deny claims, this can be frustrating but always remember claimants have 120 days from the date they receive their claim determination to file an appeal, or, redetermination request. There are two ways claimants may file a Medicare redetermination form.

What is A Medicare Redetermination Form

First, patients may fill out a downloadable form, CMS-20027 and file it with the particular Medicare Administrative Contractor (MAC) who made the original decision; this information may be obtained from the MSN or the RA. The second option available to claimants includes filing a typed or written request containing their name, Medicare Health Insurance Claim number, specific services needing to be readdressed, service date, the signature of beneficiary or beneficiary’s representative and a brief paragraph why the claimant disagrees with the Medicare Administrative Contractors initial determination. Make sure to include all of the necessary documents supporting your position in your Medicare redetermination form.

Medicare Administrative Contractors

Filing the Medicare redetermination form is claimant’s first step in the appeals process for filing grievances about claim determinations. A MAC can reject these requests if the claimant fails to file the appropriate paperwork within the allotted period of time (120 days), or if they find a lack of evidence for the good cause of late filing.

Those whose Medicare redetermination forms are dismissed by a certified administrative contractor may dispute the determination by requesting that a Qualified Independent Contractor review the MAC’s reasons for dismissal. Claimants also have the option to request that contractors vacate the dismissal on appropriate grounds.

5 Levels of Appeals

Essentially, there are five levels to the Medicare Part A and B appeals process, these are:

  1. First Level of Appeal - Filing a Redetermination form with a Medicare Administrative Contractor. This must be completed within 120 days from the time they claimants receive their initial claim determination.
  2. Second Level of Appeal - Filing a Reconsideration form with a Qualified Independent Contractor. The reconsideration form must be completed within 180 days from receiving your Redetermination decision.
  3. Third Level of Appeal - Request a hearing by an ALJ for a decision by the Office of Medicare Hearings and Appeals OMHA. A hearing must be requested within 60 days of claimant’s receipt of Reconsideration decision.
  4. Fourth Level of Appeal - A review by the Medicare Appeals Council. A review request must be made within 60 days of the beneficiary receiving OMHA’s decision.
  5. Fifth Level of Appeal - Judicial review in Federal District Court. Any claimant who is still unhappy with the decision made by the Medicare Appeals Council may file an action in a Federal District Court within 60 days from receiving notice from the Medicare Appeals Council.

How To Request A Redetermination

If the beneficiary decides they are unsatisfied with the redetermination decision, they may file a Medicare reconsideration form with a qualified independent contractor, or QIC. Appellants have 180 days from the date they receive their written redetermination decision to file their Medicare reconsideration form.

Initially, Medicare recipients will be notified of their redetermination decision through a Medicare summary or redetermination notice within the mail. Once Medicare recipients receive this notice, they may file a Medicare reconsideration form following the instructions located on the summary notice.

What Should Be Included In Your Reconsideration Request

The Medicare reconsideration form may be filed with a QIC using one of two methods. Firstly, claimants can download the CMS-20033 form, or, they may file a typed/written request containing their name, insurance claim number, services to be reconsidered, the signed name of the beneficiary; include the written name of the Medicare Administrative Contractor who made the redetermination decision.

Be sure to also include any documentation that supports your reasoning as to why the redetermination decision made by the MAC is incorrect. Lastly, include a copy of your Medicare summary notice and Remittance advice along with your Medicare reconsideration form to the appropriate QIC.

Does Medicare Accept Corrected Claims

If your Medicare claim is not accepted for various reasons don’t worry as it is possible to submit a corrected claim. The Fiscal Intermediary Shared System, or, FISS for short, is a system where possible errors in claims are identified. If your claim contains errors like missing information, otherwise known as an RTP, you can file a corrected claim. Return to Provider (RTP) errors are the only errors eligible for a claim correction. Other errors like medically denied line items must be remedied using the appeals process.

Why Your Appeal May Be Dismissed

There are a few common reasons why a claimant’s appeal may be rejected. One of those reasons is the treatment requested is not medically necessary. Basically, this means is that claimants must prove their medical provider thinks the recommended approach to treatment is a medical necessity. Providing supporting evidence showing a treatment as a Medical necessity is best met with a written letter by your doctor stating the reasons why this treatment is needed.

Another common reason appeals are rejected is because the treatment requested is experimental. Although experimental medical treatments may be covered, the claimant must prove: that it is a medical necessity, less expensive than the standard treatment, the only treatment that will work and is a procedure that’s been covered in the past for other patients.

Lastly, lack of payment is another common reason why claims are rejected. If your claim was denied because of lack of payment on your policy you can write a formal letter explaining why the payment wasn’t made and make the necessary payments.