Medicare redetermination

Every Original Medicare appeal starts here, with the contractor that made the decision. You file in writing with the MAC named on the remittance or the Medicare Summary Notice, using form CMS-20027 or a letter that gives the beneficiary’s name and Medicare number, the services and dates of service, who is filing and why the decision is wrong, and you attach whatever supports the argument¹. No minimum dollar amount has to be in dispute¹.

The window is 120 days from the date you receive the initial determination, and receipt is presumed 5 calendar days after the date on the notice unless there is evidence otherwise¹. The MLN booklet ties that date to the electronic or paper remittance that carries the initial determination and treats the request as filed on the day the contractor receives it². MACs generally decide within 60 days of receiving the request. The answer comes as a Medicare Redetermination Notice, or as a revised remittance when the MAC reverses itself and pays the claim in full². A request filed late without good cause can be dismissed².

Overpayments add a shorter clock to the same appeal. After an overpayment demand letter, recoupment from your Medicare payments begins on day 41 unless a valid redetermination request reaches the MAC by the 30th calendar day after the letter’s date³. One thing a redetermination is not for: MACs do not process corrections of minor errors and omissions through the appeals process¹. Fix a clerical slip through the MAC’s claim correction route and save the appeal for a decision you can contest with records.