How to do Medicare redetermination request

Filing a Request for a Redetermination

The first level of appeal is a redetermination.  A redetermination is an independent reexamination of an initial claim redetermination.  A redetermination can be requested if you are dissatisfied with the initial processing of your claim.  A redetermination must be filed within 120 days of the date of receipt of the initial claim determination notice.  All requests for redeterminations must be filed in writing.  Regulations dictate that requests for redeterminations may not be filed over the telephone.

Medicare providers who submit claims to Medicare Administrative Contractors (MACs) have the same right to appeal claims as beneficiaries.  This means the provider does not need to submit an Appointment of Representative form with an appeal request.

Highmark Medicare Services has developed the Medicare Part A Redetermination Request Form for your use. A Medicare Redetermination Request form should be completed for each claim in question.  Request forms should be mailed to Highmark Medicare Services using the following address and post office boxes to submit requests for claim redeterminations (first level appeals):

Medicare Appeals
Highmark Medicare Services
PO Box 89XXXX
Camp Hill, PA 17089-XXXX
Substitute the XXXX with the appropriate PO Box number and 4 digit zip from the table below:

All written requests for a redetermination must contain the following items:

• The beneficiary name;
• The beneficiary Medicare number;
• The specific service(s) and/or item(s) for which the redetermination is being requested;
• The specific date(s) of service; and
• The printed name and signature of the requestor.

Your appeal request will be dismissed if any of the above information is not included with the request

Appeals: What happens to an incomplete redetermination request?

Answer:

An incomplete redetermination request is any correspondence received by our redetermination department that does not specifically identify all of the following information:
Beneficiary name
Medicare health insurance claim (HIC) number
The specific service(s) and/or item(s) for which the redetermination is being requested
The specific date(s) of the service
The name and signature of the appellant or the representative of the appellant
You have 120 days from the initial determination (date on the remittance notice) to request a redetermination. The notice of initial determination is presumed to be received 5 days from the date of the notice.  If your request is incomplete and returned to you, your request may be delayed and consequently may not meet the timely redetermination request requirement.

To ensure that your redetermination request contains all of the required information, we strongly encourage you to submit your request on a Railroad Medicare Redetermination request form or through our eServices portal. Redetermination request forms can be found by accessing ‘Forms’ under the Top Links section of our home page. For more information on submitting a redetermination request through eServices see the following article ‘More Appeals Forms Now Available in eServices’.