Redetermination Request Form
This form may be used to request a redetermination for Medicare Part B services. A redetermination is the first level of the Medicare Appeals Process. All requests should be submitted within 120 days of the initial claim determination.
Appellants should attach any supporting documentation to their redetermination request. Contractors will generally issue a decision (either a letter or a revised remittance advice) within 60 days of receipt of the redetermination request.
Please be advised, CMS has instructed all contractors to no longer
correct minor errors and omissions on claims through the appeals
process. Please see MLN
Matters Article SE0420 
on the CMS Web site for more information.
Redetermination requests can be made, but are not limited to the following situations:
- Modifier is being added to support a global denial.
NOTE: If adding modifiers 25, 24, 58, 78 or 79, please include comments supporting the reason for adding these modifiers. - Claim denied for a duplicate service.
NOTE: Documentation should be included to support each service billed. - Ambulance denials.
NOTE: Run tickets should be included to support each trip. - Charges denied as Part A because the patient was seen in the
office prior to admission in the hospital.
NOTE: Documentation should be included to support the office service. - Claim denied as not medically necessary and a GA modifier has
been added to the claim.
NOTE: A copy of the Advance Beneficiary Notice should be included with the request.
In order to process a Redetermination request, we also need the following pieces of information:
- The beneficiary's name
- The HICN
- The DOS and the name of the service or item
- The name and signature of the person filing the Redetermination request
