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) - 120 days to file
2. Reconsideration by Qualified Independent Contractor (QIC) - 180 days to file
3. Hearing before Administrative Law Judge (ALJ) - 60 days to file
4. Medicare Appeals Council Review - 60 days to file
5. Federal District Court Review - 60 days to file

No minimum amount in controversy for redetermination.

Medicare Redetermination Request

[Date]

VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED

[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, I hereby request a redetermination of the initial determination dated [DATE] that denied/reduced payment for Medicare-covered services. This appeal is timely filed within 120 calendar days of the date I received the Medicare Summary Notice (MSN) or Remittance Advice (RA).

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:
☐ 3-day hospital stay requirement not met (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
☐ Certificate of Medical Necessity (CMN) - for DME
☐ Plan of care
☐ Referral documentation

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

Section 7: Assignment of Appeal Rights (If Applicable)

Complete only if beneficiary is assigning appeal rights to provider

Assignment Requirements (42 CFR 405.912)

☐ The beneficiary is NOT assigning appeal rights - Skip to Section 8

☐ The beneficiary IS assigning appeal rights to:

Required Statements:

By signing below, the beneficiary:
1. Assigns appeal rights for the specific claim(s) listed above to the assignee
2. Authorizes the assignee to file appeals and receive appeal correspondence
3. Understands the assignee waives the right to collect payment from the beneficiary for amounts in dispute

Beneficiary Signature (assigning rights): ______________________________________________

Date: ______________________________________________

Assignee Signature (accepting assignment and waiving collection): ______________________________________________

Date: ______________________________________________

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:
☐ Power of Attorney attached
☐ CMS-1696 (Appointment of Representative) attached
☐ Court order attached
☐ Other legal authority: ______________________________________________

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 MAC will conduct an independent review of my claim
• The reviewer will consider all evidence submitted with this appeal
• 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 you receive the initial determination
• Receipt is presumed 5 days after the date on the MSN/RA unless you can show otherwise

Date of Initial Determination: ______________________________________________

Presumed Receipt Date (+ 5 days): ______________________________________________

120-Day Filing Deadline: ______________________________________________

Decision Timeline

• MAC must issue decision within 60 calendar days of receipt
• If additional evidence submitted, timeline extends by 14 days per submission
• Decision will be sent to all parties

What Happens Next

1. MAC acknowledges receipt of your appeal
2. Independent reviewer examines claim and evidence
3. Reviewer may contact provider for additional information
4. Written decision (Notice of Redetermination) issued
5. If unfavorable, instructions for QIC reconsideration provided

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 within 180 days of redetermination
- Independent review by Qualified Independent Contractor
- No minimum amount in controversy

Level 3 - ALJ Hearing:
- File within 60 days of QIC reconsideration
- Amount in controversy must be at least $180 (2024)
- Can combine claims to meet threshold

Level 4 - Medicare Appeals Council:
- File within 60 days of ALJ decision
- Amount must be at least $1,840 (2024)

Level 5 - Federal District Court:
- File within 60 days of Appeals Council decision
- Amount must be at least $1,840 (2024)

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.