How to receive a successful decision on Redetermination request

To ensure that you receive a successful decision on single or multiple-claim appeal requests, review the six key items listed below:

1. Requests submitted without all appropriate signed documentation might result in an unfavorable decision for the provide

2. All applicable claim lines and claim details are reviewed for medical necessity, correct coding and supportive documentation

3. Additional claims pertaining to the questioned service are subject to review and possible adjustment

4. The number of claims can be reduced by ensuring that you submit all appropriate supporting medical record documentation, including applicable modifiers and ICD-9 codes, with the initial claim

5. All requests must contain the name and legible signature of the person requesting the appeal 6. If a claim is submitted and denied multiple times, the time limit to request a redetermination starts with the first claim determination Second Level Appeal Request: Reopening

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