CMS Pub. 100-04, ch. 29, § 310.1

A request for redetermination must be filed with the contractor in writing. The request may be made by a

party to the appeal as defined in §260 and/or the party’s representative as defined in §270. Appeal requests

submitted electronically via a facsimile or secure Internet portal/application shall be considered to have been

received in writing.

NOTE: Contractors are not required to utilize a facsimile and/or a secure Internet portal/application for

performing appeals activities. Contractors may not require an appellant to file an appeal electronically (e.g.,

via facsimile and/or a secure Internet portal/application). Submission of appeal requests via facsimile or a

portal/application shall be at the discretion of the appellant. Contractors shall continue to accept appeal

requests in hardcopy via mail.

A. Written Redetermination Requests Filed on Behalf of the Beneficiary

Someone other than an appointed representative may submit a written request for redetermination on behalf

of a beneficiary. Persons who often act on behalf of a beneficiary in filing a redetermination request include:

the spouse, parent, child, sibling, neighbor or friend. Beneficiary advocacy groups and Members of Congress

may also submit a request for redetermination on behalf of a beneficiary (see §310.1.A.1 for further

discussion on requests submitted by Members of Congress).

The contractor honors the request for redetermination if the request clearly shows the beneficiary knew of or

approved the submission of the request for redetermination (e.g., the request is submitted with a written

authorization from the beneficiary or with the beneficiary’s MSN). However, if the contractor has

information that the redetermination request was not submitted at the request of the beneficiary, the

contractor does not conduct the redetermination unless and/or until it receives confirmation from the

beneficiary that the request was submitted with the beneficiary’s approval.

If a redetermination request is submitted by an individual who is not the beneficiary’s appointed

representative, all written notices related to the appeal are sent only to the beneficiary, not the individual

making the request for redetermination. In addition, if the contractor honors a request for redetermination

filed by someone other than the beneficiary or the beneficiary’s appointed representative, the contractor

should contact the beneficiary (or an appointed/authorized representative if applicable) if further information

is needed to process the redetermination.

NOTE: An authorized representative is an individual authorized under State or other applicable law to act

on behalf of a beneficiary in an appeal, and has all of the rights and responsibilities of a beneficiary with

respect to the appeal. An authorized representative does not need to secure an appointment of representative

from the beneficiary in order to file an appeal or obtain/receive information related to the appeal. See

§270.1.1 for additional information regarding authorized representatives.

The person submitting the request does not automatically become the representative until and unless an

appointment of representative form or other written statement is completed (see §270 for instructions on

developing an incomplete or absent appointment of representative).

There will be circumstances where the mental and/or physical incapacity of the beneficiary becomes an

issue. Based on all the documented medical information available, the contractor may decide to allow the

person submitting the request for redetermination to act on behalf of a beneficiary who is mentally or

physically incapacitated. The contractor’s decision, as well as the beneficiary’s incapacitation, should be

documented in the file and supported by relevant medical documentation.

1. Requests for Redetermination Submitted by Members of Congress

When the contractor has honored a request for redetermination filed by a Member of Congress pursuant to a

Congressional inquiry made on behalf of a beneficiary or provider, physician or other supplier, the

contractor may continue to provide the Member of Congress with status information on the appeal at issue.

Status information includes the progression of the appeal through the administrative appeals process,

including information on whether or when an appeal determination or decision has been issued and what the

decision was (e.g., favorable, unfavorable, partially favorable), but does not include release of personal

information about a beneficiary that the Member of Congress did not already have in his/her possession. A

beneficiary may want a Member of Congress to obtain more detailed information about his/her appeal

without appointing the Member of Congress as a representative. In this case, it would be necessary for the

beneficiary to sign a release of information. The contractor must accept any of the following as releases of

information:

• A signed copy of correspondence from the beneficiary expressing a desire for the congressional

office to obtain information on his/her behalf;

• A release of information form developed by the congressional office; or

• A release of information form developed by the contractor for this purpose.

If the Member of Congress expresses an interest in acting as the representative of a beneficiary or of a

provider, physician, or other supplier, the party must complete an appointment of representative form or

written statement.

B. What Constitutes a Request for Redetermination

1. Written Requests for Redetermination Made by Beneficiaries

Beneficiaries may request a redetermination by submitting a copy of their MSN, by filing a completed Form

CMS-20027 or by submitting a letter that indicates dissatisfaction with a claim determination. As noted

above, appeal requests received via a facsimile or secure Internet portal/application shall also be considered

received in writing. Requests for redetermination may be submitted in situations where beneficiaries assume

that they will receive a redetermination by questioning a payment detail of the determination or by sending

additional information back with the MSN, but don’t actually say: I want a review. For example, a written

inquiry stating, “Why did you only pay $10.00?” is considered a request for redetermination. Common

examples of phrasing in letters from beneficiaries that constitute requests for redetermination include, but are

not limited to the following:

• “Please reconsider my claim.”

• “I am not satisfied with the amount paid - please look at it again.”

• “My neighbor got paid for the same kind of claim. My claim should be paid too.”

The request may contain the word appeal or review. There may be instances in which the word review is

used but where the clear intent of the request is for a status report. This should be considered an inquiry.

2. Written Requests for Redetermination Submitted by a State, Provider, Physician or Other

Supplier

States, providers, physicians, or other suppliers with appeal rights must submit written requests via mail,

facsimile or secure Internet portal/application (if the contractor chooses to receive requests via facsimile or

CMS approved secure Internet portal/application) indicating what they are appealing and why. A

redetermination request may be submitted using:

a. A completed Form CMS-20027 constitutes a request for redetermination. “Completed” means

that all applicable spaces are filled out and all necessary attachments are included with the request.

The form can be found on the CMS website at:

http://www.cms.gov/cmsforms/downloads/cms20027.pdf

b. A written request/letter. At a minimum, the request must contain the following information:

1. Beneficiary name;

2. Medicare number;

3. The specific service(s) and/or item(s) for which the redetermination is being requested;

4. The specific date(s) of the service; and

5. The name of the party or the representative of the party.

Frequently, a party will write to a contractor concerning the initial determination instead of filing Form

CMS-20027. How to handle such letters depends upon their content and/or wording. A letter serves as a

request for redetermination if it contains the information listed above and either: (1) explicitly asks the

contractor to take further action, or (2) indicates dissatisfaction with the contractor’s decision. The contractor

counts the receipt and processing of the letter as an appeal only if it treats it as a request for redetermination.

NOTE: The details of its actions must be detailed (e.g., when action was taken and what was done) for

possible subsequent evidentiary and administrative purposes.

c. A secure Internet portal/application. If a contractor has received CMS approval for the use of a

secure Internet portal/application to support appeals activities, appellants may (but are not required

to) submit redetermination requests via the secure Internet portal/application. Written requests

submitted via the portal/application shall include the required elements for a valid appeal request as

outlined above under §310.1.B.2.b.

NOTE: Some redetermination requests may contain attachments. For example, if the RA is attached to the

redetermination request that does not contain the dates of service on the cover and the dates of service are

highlighted or emphasized in some manner on the attached RA, this is an acceptable redetermination

request.

Where the required information is not listed on the request form but is provided within the documents or

attachments submitted with the appeal, the request substantially complies with the requirements established

in 42 CFR 405.944. MACs shall not dismiss requests under 42 CFR 405.952(b)(2) when redeterminations

substantially comply with requirements.

3. How to Handle Incomplete Requests for Redetermination:

If any of the above information referenced in Section 2 is not included with an appeal request submitted by a

party or their representative (other than a beneficiary, or a beneficiary’s representative), the request is

considered incomplete and the contractor issues a dismissal notice with an explanation of the information

that must be included (see §310.6 for more information on dismissals). Contractors should not consider

beneficiary requests as incomplete, whether filed by the beneficiary or by their representative. Contractors

must contact beneficiaries (or their representatives), when necessary, to obtain missing information needed

to process the redetermination.

4. How to Handle Multiple Requests for Redetermination for the Same Item/Service:

a. Duplicate requests (multiple requests from same party) while an appeal is pending. If an appeal

for an item or service is pending and the appellant submits a duplicate request for redetermination, the

contractor combines the requests into one redetermination. The contractor shall include verbiage

indicating that duplicate requests for redetermination had been received (on what dates and via what

venues, if multiple venues were utilized). Adjudication time frames are still based on the first request

for redetermination. NOTE: See 310.4.D.4 for extending adjudication timeframes if additional

information is submitted with the second appeal request.

If the contractor identifies a pattern in which an appellant or groups of appellants are repeatedly

submitting duplicate requests for redetermination, the contractor shall take additional steps to educate

the appellant regarding the appeals process.

b. Multiple requests from different parties while an appeal is pending. If an appeal for an item or

service is pending and another party to the redetermination submits a request for redetermination, the

contractor shall combine the redetermination requests and issue a decision within 60 days of the latest

filed request, in accordance with 42 CFR 405.944(c).

When issuing the decision or dismissal notice, the contractor shall include verbiage indicating that

requests for redetermination had been received from multiple parties (on what dates and via what

venues, if multiple venues were utilized) so that it is clear to the parties that the decision or dismissal

was issued timely in accordance with 42 CFR 405.950(b)(2).

c. Duplicate or multiple requests when an appeal is complete. If a decision or dismissal notice has

been issued (including an MSN or RA for a fully favorable decision), and the contractor receives an

additional request for redetermination for that item/service (a duplicate request from the appellant or a

subsequent request from a different party), the contractor shall treat the additional request as an

inquiry. The contractor directs the party to file a request for reconsideration with the appropriate QIC.

d. Workload -Whenever the contractor combines duplicate or multiple requests for redetermination as

explained above, the contractor shall ensure that the workload reporting reflects one redetermination

receipt and one redetermination completed.

NOTE: I f a party files a request for reconsideration with the contractor after a redetermination decision or

dismissal notice has been issued, the contractor treats the reconsideration request as misfiled and forwards

the request to the QIC for a reconsideration in accordance with §320.1.B.

Contractors shall not issue a dismissal notice in response to a duplicate request or multiple requests for

redetermination.

NOTE: In accordance with IOM 100-04, chapter 29, section 310.6.3, if an appellant requests that the

contractor vacate its dismissal action, or an appellant refiles a corrected appeal in response to a dismissal,

and the contractor determines that it cannot vacate the dismissal, then it sends a letter notifying the appellant

accordingly. If evidence or information not previously submitted with the redetermination request is

submitted with the request to vacate the dismissal, the letter must specifically address that new evidence or

information. The contractor shall not issue a second dismissal notice to the appellant.

5. Letters and Calls That Are Considered Inquiries

See IOM 100-09, Medicare Contractor Beneficiary and Provider Communications Manual. The contractor

considers the letter or telephone call an inquiry (i.e., not an appeal request) if:

• It is clearly limited to a request for an explanation of how Medicare calculated payment. (For

example, if a physician sends a letter inquiring about the payment rate for a particular item or

service, but it is not in connection with a claim that has been processed for the item or service,

the letter is treated as an inquiry. However, if the physician questions the amount paid for an

item or service on a claim that was processed to payment, and asserts additional payment is

warranted, the contractor handles this as an appeal of the payment amount, even if the

item/service was paid under a fee schedule. See §200.C.3);

• The party is only asking for the status on a previously submitted appeal request or

correspondence. The contractor states in its reply that is responding to a status request. It does

not use the word “review” in its reply;

• It is a request for information;

• It is a request for redetermination, made by a party other than the appellant, for the same

item/service for which a decision or dismissal notice has already been issued. In responding to

the inquiry, the contractor shall inform the party making the request that a decision has been

issued and the party should file a reconsideration with the appropriate QIC. Contractors shall not

issue a dismissal notice.

• It is a request for redetermination, submitted by an individual (who is not an appointed or

authorized representative), filed on behalf of a provider, physician, supplier, or other non-beneficiary party, and the request does not include an appointment instrument (see

§270.1.6.B.2). The contractor follows the procedures in §270.1.6.B.2.

• The party asks only for a second copy of a notice.

NOTE:

• If the contractor receives a ‘request for reconsideration’ (assuming the appellant is using the wrong

form or incorrect terminology), but determines that a redetermination has not been conducted, the

contractor does not forward the request to the QIC. The contractor shall consider the request as a

redetermination request.

• If the contractor receives a ‘request for reconsideration’ from a party, or a 'request for reconsideration'

that was mistakenly directed to them by another contractor, and the contractor has already conducted a

redetermination, the contractor shall forward the request to the appropriate QIC, along with the case

file within 60 calendar days of receipt in the corporate mailroom. Refer to §320.1.

Parties to a claim must file a request for redetermination with the proper contractor based on the claims

processing jurisdiction rules established by the Medicare program. Jurisdiction is established based on

either the State where the service was provided (for Part B claims not involving DME), the State where the

beneficiary resides (for Part B DME claims only), or the location of the A/B MAC (for Part A provider

claims). There may be instances where requests for redetermination are directed to the wrong contractor.

Contractors shall have standard operational procedures, including maintaining a record of these cases, in

place to ensure that misfiled requests are forwarded to the proper contractor jurisdiction within 60 calendar

days of receipt.

Refer to § 310.4.A for information on determining whether misfiled requests for appeal are processed in a

timely manner.