Medicare Appeal - Redetermination Request (Part A and Part B)

Medicare Appeal - Redetermination Request (Part A and Part B)

Instructions for Use

This template is for the first level of the Medicare appeals process - requesting a redetermination of an initial determination by a Medicare Administrative Contractor (MAC). This applies to Original Medicare (Part A and Part B) claims.

Medicare Appeals Process (5 Levels):

1. Redetermination by MAC (this template) - generally 120 calendar days after receipt of the initial determination
2. Reconsideration by Qualified Independent Contractor (QIC) - generally 180 calendar days after receipt of the redetermination
3. OMHA review by an Administrative Law Judge (ALJ) or attorney adjudicator - generally 60 calendar days after receipt of the QIC reconsideration
4. Medicare Appeals Council Review - generally 60 calendar days after receipt of the OMHA decision or dismissal
5. Federal District Court Review - generally 60 calendar days after receipt of the Council decision, subject to the judicial amount-in-controversy requirement

No minimum amount in controversy for redetermination.

Medicare Redetermination Request

[Date]

VIA [MAIL / FAX / APPROVED ELECTRONIC PORTAL AS DIRECTED IN THE INITIAL NOTICE]

[Medicare Administrative Contractor Name]
[Redetermination Unit]
[Street Address]
[City, State, ZIP]

MEDICARE REDETERMINATION REQUEST - LEVEL 1 APPEAL

Re: Request for Redetermination of Initial Determination

Dear Redetermination Unit:

Pursuant to 42 CFR 405.940 through 405.944, I request a redetermination of the initial determination dated [DATE] concerning the item(s) or service(s) identified below. This request is being filed with the contractor identified in the initial notice within 120 calendar days after receipt of that notice. [IF LATE: A written good-cause extension request and supporting evidence are attached under 42 CFR 405.942(b).]

Section 1: Beneficiary Information

Medicare Coverage Type:
☐ Part A (Hospital Insurance)
☐ Part B (Medical Insurance)
☐ Both Part A and Part B

Section 2: Initial Determination Information

Claim Details

Service Information

Total Amount in Dispute: $ ______________________________________________

Provider Information

Facility Information (if applicable)

Section 3: Reason for Denial (From MSN or RA)

Medicare's Stated Reason for Denial (check all that apply):

Coverage Denials:
☐ Service not covered by Medicare
☐ Not medically necessary
☐ Experimental/investigational
☐ Maintenance therapy (no longer improving)
☐ Custodial care
☐ Not reasonable and necessary
☐ Excluded by statute

Technical Denials:
☐ Claim filed too late
☐ Medicare is secondary payer
☐ Duplicate claim
☐ Missing/invalid information
☐ Provider not enrolled in Medicare
☐ Service not furnished as billed
☐ Coding error

Part A Specific:
☐ Qualifying inpatient-stay issue stated in the denial (SNF)
☐ Inpatient status not justified (should be outpatient/observation)
☐ Admission not medically necessary
☐ Patient status change denial

Part B Specific:
☐ Advance Beneficiary Notice (ABN) issue
☐ Exceeded frequency/duration limits
☐ Service bundled with another
☐ Off-label use not supported

Denial Code(s): ______________________________________________

Remark Code(s): ______________________________________________

Exact Language from Denial:

_______________________________________________________________________________

_______________________________________________________________________________

Section 4: Grounds for Appeal

Why the Initial Determination Should Be Overturned

☐ The service IS covered by Medicare because:

_______________________________________________________________________________

_______________________________________________________________________________

☐ The service IS medically necessary because:

_______________________________________________________________________________

_______________________________________________________________________________

☐ The technical denial reason is incorrect because:

_______________________________________________________________________________

_______________________________________________________________________________

☐ The claim was properly filed/coded because:

_______________________________________________________________________________

_______________________________________________________________________________

☐ Other grounds for reversal:

_______________________________________________________________________________

_______________________________________________________________________________

Section 5: Detailed Statement of Appeal

Medical Necessity Statement

Diagnosis/Condition:

_______________________________________________________________________________

Medical History Relevant to Claim:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Why Services Were Medically Necessary:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Expected/Actual Outcome of Treatment:

_______________________________________________________________________________

_______________________________________________________________________________

Coverage Argument

Medicare Benefit Category:

_______________________________________________________________________________

Coverage Criteria Met:

_______________________________________________________________________________

_______________________________________________________________________________

Relevant Medicare Policy:
☐ Medicare Benefit Policy Manual Chapter: ______________
☐ National Coverage Determination (NCD): ______________
☐ Local Coverage Determination (LCD): ______________
☐ Local Coverage Article (LCA): ______________

Section 6: Supporting Documentation

Documents Submitted with This Appeal

Medicare Notices:
☐ Medicare Summary Notice (MSN)
☐ Remittance Advice (RA)
☐ Initial Determination Letter
☐ Advance Beneficiary Notice (ABN) - if applicable

Medical Records:
☐ Physician's orders
☐ Progress notes
☐ Hospital records
☐ Operative report
☐ Discharge summary
☐ Therapy notes
☐ Lab results
☐ Imaging reports

Physician Documentation:
☐ Letter of medical necessity
☐ DME order and supplier documentation
☐ Plan of care
☐ Referral documentation

Other:
☐ Prior authorization (if applicable)
☐ Itemized bill
☐ Assignment of benefits
☐ Other: ______________________________________________

Section 7: Assignment of Appeal Rights (If Applicable)

Do not use this template as the assignment instrument. Under 42 CFR 405.912, a valid assignment of appeal rights must use the current CMS standard form, be signed by the beneficiary and eligible provider or supplier, identify the item or service, contain the required collection waiver, and be submitted when the appeal is filed.

☐ No assignment of appeal rights is being made.

☐ Current CMS standard assignment-of-appeal-rights form is completed and attached.

Assignee provider or supplier: ______________________________________________

Item(s) or service(s) covered by assignment: ______________________________________________

Counsel confirmed assignee eligibility under 42 CFR 405.912(a)-(b): ☐ Yes

Section 8: Authorized Representative (If Applicable)

Complete if someone other than the beneficiary is filing this appeal

☐ Beneficiary is filing on own behalf - Skip to Section 9

☐ Representative is filing on beneficiary's behalf

Authority to Represent:
☐ CMS-1696 (Appointment of Representative) attached
☐ Written appointment containing all elements required by 42 CFR 405.910 attached
☐ Other authority accepted under current CMS rules: ______________________________________________

Section 9: Beneficiary Certification and Signature

I certify that the information provided in this redetermination request is true and correct to the best of my knowledge. I understand that:

• The redetermination will be performed by an individual who was not involved in the initial determination
• The contractor will adjudicate the claim based on the evidence of record
• I have the right to submit additional evidence
• I will receive a written decision explaining the outcome
• If the redetermination is unfavorable, I have the right to appeal to a Qualified Independent Contractor (QIC)

Beneficiary Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

Section 10: Provider/Supplier Attestation (If Applicable)

Complete if provider is submitting appeal or supporting documentation

I attest that the services billed were provided as described, were medically necessary, and that the documentation submitted accurately reflects the care provided.

Provider Signature: ______________________________________________

Printed Name and Credentials: ______________________________________________

Date: ______________________________________________

Important Deadlines and Information

Filing Deadline

• 120 calendar days from the date the party receives the notice of initial determination
• Receipt is presumed 5 days after the date on the MSN/RA unless you can show otherwise
• The request is filed when the contractor receives it, not when it is mailed
• The contractor may extend the deadline for good cause after a written request that explains the delay and includes supporting evidence

Date of Initial Determination: ______________________________________________

Presumed Receipt Date (+ 5 days): ______________________________________________

120-Day Filing Deadline: ______________________________________________

Decision Timeline

• The contractor generally must issue a redetermination or dismissal within 60 calendar days after receiving a timely request, subject to regulatory exceptions and extensions
• If a party submits additional evidence after filing, the timeline may extend by up to 14 calendar days for each submission
• Notice is transmitted as required by 42 CFR 405.956: to all parties for an affirmance or partial affirmance, and to the appellant for a full reversal

What Happens Next

1. The contractor reviews the claim and evidence of record through a reviewer not involved in the initial determination.
2. The contractor issues a written redetermination or dismissal within the applicable adjudication period.
3. A decision affirming the initial determination in whole or in part explains the result and provides QIC reconsideration instructions.

MAC Contact Information

Find Your MAC

Part A and Part B claims are processed by regional MACs. Find yours at:
https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs

Tracking

Appeal Rights After Redetermination

If redetermination is unfavorable, you may request:

Level 2 - QIC Reconsideration:

• File generally within 180 calendar days after receipt of the redetermination; follow the notice
• Independent review by Qualified Independent Contractor
• No minimum amount in controversy

Level 3 - OMHA Review:

• File generally within 60 calendar days after receipt of the QIC reconsideration; follow the notice
• The amount remaining in controversy must be at least $200 for 2026
• Claims may be aggregated only when the regulatory conditions are met

Level 4 - Medicare Appeals Council:

• File generally within 60 calendar days after receipt of the OMHA decision or dismissal; follow the notice
• CMS does not list a separate amount-in-controversy threshold for Council review

Level 5 - Federal District Court:

• File generally within 60 calendar days after receipt of the Appeals Council decision; follow the notice and 42 CFR 405.1130 through 405.1136
• The amount remaining in controversy must be at least $1,960 for 2026

Resources

• Medicare Appeals: https://www.medicare.gov/claims-appeals/
• CMS Appeals Information: https://www.cms.gov/medicare/appeals-grievances/fee-for-service
• 42 CFR Part 405 Subpart I: https://www.ecfr.gov/current/title-42/part-405/subpart-I
• Medicare Administrative Contractors: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/
• 1-800-MEDICARE: 1-800-633-4227

This template is provided for informational purposes only and does not constitute legal advice. Consult with a Medicare appeals specialist or healthcare attorney for specific legal guidance.