Redetermination and Reconsideration Processing
For partially favorable decisions and unfavorable decisions, the parties will receive a written redetermination decision with the rationale for the decision as well as notice of effectuation via a MSN or RA. If you do not agree with the decision, you will be provided instructions on how to pursue the next level of appeal, reconsideration by the QIC. The decision will also include a Reconsideration Request Form that is to be submitted to the QIC if you wish to appeal the redetermination decision.
A. Letter of Written Assurance
Prior to paying a provider for fully favorable or partially favorable cases where the beneficiary was previously liable, the MAC must ascertain whether the provider has been reimbursed for the previously denied services from another source. The MAC will withhold the Medicare reimbursement until the party has assured, in writing, that any prior payment has been refunded.
Returning a Letter of Assurance promptly will result in quicker payment to you. Only after the Letter of Assurance has been received will a claim adjustment be initiated to make payment. If no Letter of Assurance is received, no payment will be made.