Redetermination (First Level Appeal) Submission

The Redetermination (First Level Appeal) Submission page allows you to identify a claim or claims that you believe are not related to this case and include them in a request for redetermination. You will be required to select at least one claim on this page, and provide at least one of a reason (per claim, other than "Other") or documentation (in the form of written notes in the text box provided or via uploaded documents) to support the request on a subsequent page in this process.

Once Medicare receives your redetermination, they will review the request and decide if the original demand amount is correct and send you a letter that explains the reasons for the decision. This letter will also explain the steps you will need to follow to appeal that decision if it is less than fully favorable to you.

Note: After submitting a redetermination request successfully, you can view a read-only version of that request by clicking the View/Submit Redetermination (First Level Appeal) action on the Case Information page, or by clicking the Waiver/Redetermination/Appeal/Compromise tab on the Case Information page to see the following details for the first redetermination that has been requested for the current Case ID: Received (date), Decision , and the Decision Date . Additionally, you can view activity details for a successful redetermination submitted for a case on the Account Activity page

Redetermination Timeline

The following information provides a timeline for each phase of the redetermination process:

You have 125 calendar days from the mail date of the demand letter to submit a redetermination request.
Interest begins to accrue if you do not file a redetermination request within the first 30 days after the date of the demand letter.
Once the redetermination request is submitted, the BCRC or CRC will make a decision on the case within 60 days. While your redetermination request is being processed at any level of review, no collection action will be taken.
If additional documentation is submitted after the redetermination was requested, the BCRC or CRC have an additional 14 days (equaling 74 days from the original redetermination request) to make a decision.

Viewing Submitted Redetermination Request

After submitting a redetermination request successfully, whether by mail or on the MSPRP, you can view that request in one of two ways. When there is still the possibility of submitting further redetermination requests (see below), clicking the View/Submit Redetermination (First Level Appeal) action on the Case Information page will (after you click through the warning page) show you all the claims attached to your case. Any claims with submitted redetermination requests will be shown as read-only; any claims with successful (in your favor) redeterminations will not appear (that is, disassociated from the case); and any claims still available for redetermination will be shown as such on the submission version of the page.

At any time in the process, you can view submitted claims by clicking the Waiver/Redetermination/Appeal/Compromise tab on the Case Information page to see the following details for the redetermination(s) that has/have been requested for the current case ID: Received (date), Decision, and the Decision Date. Additionally, you can view activity details for a successful redetermination submitted for a case on the Account Activity page.

Requesting a Redetermination (First level Appeal)

To request a redetermination (first level appeal):

Click the Select for Redeterm. check boxes to select one or more available claims from the list to include with the redetermination request. Clicking Select All selects all the available claims, while Deselect All deselects all the selected claims.
Check the box in the Select for Reason column next to any selected claim for which you wish to provide a reason. Below the table, choose a reason to apply to all the selected claim(s). Click the Apply button to apply the selected reason to the selected claim(s). If you are using more than one reason, apply the reason you wish to the claims you wish, and select and apply a new reason for the next claim(s). Please submit documentation for any claims for which you don't choose a reason, or for which you select the reason "Other."
Click Continue to proceed to the Redetermination (First Level Appeal) Verification page to verify your selected claims and submit your supporting documentation.
Click Cancel to return to the Case Information page without saving any data.

Redetermination (First Level Appeal) Submission Fields

Field	Description
Clear	Click this button to remove any sorting or filtering and restore the default display of claims information.
Export	Click this button to export the listed claims shown to a spreadsheet on your computer.
Case ID	Displays the current Case ID.
Demand Amount	Displays the amount currently being demanded.
Demand Letter Date	Displays the date of the demand letter
Claims	-
Select for Redeterm.	Select the box next to the available claim(s) you wish to include for redetermination. You must select at least one claim to continue. Click the Select All or Deselect All link to select or deselect all available claims. Note: Claims already submitted for redetermination will be read-only. Redeterminations in your favor will remove the claim from the case, so those will not appear.
Select for Reason	Select the box to add or remove a reason for the redetermination request as it applies to this claim. Notes: You can only select one reason per claim, but you can select a different reason for each claim. A reason (other than "Other") or documentation is required for each claim selected. You can add documentation from the Redetermination (First Level Appeal) Verification page, after you click Continue on this page.
Claim Control ID (ICN)	Claim Number (Internal Control Number) assigned to the claim by the Medicare processing contractor. Note: The first eight characters will be masked (hidden from view) unless you are the beneficiary or logged in using multi-factor authentication.
Line #	This number indicates one or more services that were billed on a single claim per Date of Service.
Redeterm. Reason	Reason currently selected for requesting a redetermination of this claim, or the reason submitted with a prior submission. Sortable and filterable column: click the arrows in the header to sort or reverse sort order; select a reason from the drop-down menu to show only claims with that redetermination reason.
Redeterm. Received	For prior redetermination submissions, displays the method of submission (MSPRP or Mail/Fax), and if MSPRP, the date submission was made.
Total Charges	Amount billed by the provider. Sortable and filterable column: click the arrows in the header to sort or reverse sort order; type in the text box to show only claims containing the entered text .
Reimbursement Amount	Amount Medicare paid the provider.
Conditional Payment Amount	Amount due Medicare.
Select a Redetermination Reason to apply to the selected claims:	Choose a reason from the drop-down menu. This field only appears after you have selected a claim and checked the "Select for Reason" checkbox. Possible values: For BCRC cases: -Select- Duplicate Primary Payment Previous Payment to CMS/Treasury/BCRC Relatedness Treatment Ended Wrong Insurer Other For CRC cases: -Select- Benefits Exhausted Policy Cancelled Previous Payment to CMS/Treasury/CRC Relatedness Services Not Covered Treatment Ended Other
Apply	Click to apply selected reason for redetermination to selected claim(s).
Remove Reason	Click to remove reason for redetermination from selected claim(s).
Continue	Click to display the Redetermination (First Level Appeal) Verification page.
Cancel	Click to cancel the redetermination process and return to the Case Information page. No data will be saved.

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April 2024