What is Redetermination? 

Once the processing of your claim is completed, you have the right to request a redetermination if you disagree with the initial claim decision. A redetermination is the first of five appeal levels available for providers to contest initial claim determinations.

What’s new in the revised form? 

The Revised Part B Redetermination/Reopening Request Form includes all required elements of a valid request. Besides the specific state/region check boxes added to the top of the form, the revised form also offers an easier flow of information and a comprehensive list of correct mailing addresses to send your request. Note: We do not accept requests electronically at this time. Please print and mail the completed form to the mailing address noted on the form. While it is not necessary to send copies of Local Coverage Determinations (LCDs), any other supporting documentation should be included with your redetermination request.

The EDI Fax Cover Sheet should not be used to request a redetermination and should only be used to fax additional documentation to supplement your initial electronic claim submission. Redetermination requests received with the EDI Fax Cover Sheet will be returned to you with no action taken.