CMS Pub. 100-04, ch. 29, § 310.6.2

NOTE: This is a model letter and may need to be adjusted to include additional verbiage/instructions if a

MAC has received approval to receive appeal requests via a secure Internet portal/application.

(Start) EXHIBIT 2:

Model Redetermination

Dismissal Notice For

Incomplete or Invalid

Request

MONTH, DATE, YEAR

APPELLANT NAME MEDICARE NUMBER OF

ADDRESS BENEFICIARY:

CITY, STATE ZIP

CONTACT INFORMATION:

If you have questions, write or

call:

MAC Name

Address

City, State Zip

Telephone number

RE: <Include claim identifier or appeal number>

Dear <Appellant’s Name>:

This letter is in response to your appeal request (also known as a redetermination) that was received

in our office on <INSERT DATE>. The redetermination was requested for the following dates of

service <INSERT DATE(S)>). Your redetermination request has been dismissed because it did not

form a valid request for redetermination. In order to process a redetermination request, we need the

following item(s) to be addressed:

<INSERT ALL APPLICABLE INFORMATION>:

Missing Information:

• The beneficiary’s name;

• The Medicare number of the beneficiary;

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

specific date(s) of service;

• The name of the person filing the redetermination request.

Invalid Request:

• The requestor is not a proper party;

• Defective Appointment of Representation (AOR) <for non-beneficiary submitted claims only>;

• No initial determination on the claim(s) appealed; or

• Beneficiary is deceased with no remaining party or appointed representative with financial

interest.

Your request was determined to be invalid as explained above and therefore has been dismissed.

You may file your request again if it has been 120 days or less since the date of receipt of the initial

determination notice. When you file your request, please make sure you have addressed all of the

above listed items and send your request to our office at the address noted above.

If you disagree with this dismissal, you have two additional options:

1. You may request that we vacate our dismissal. We will vacate our dismissal if you demonstrate

that you have good and sufficient cause for failing to submit a valid request. Your request to vacate

this dismissal must be received at the address above within 6 months of the date of receipt this

notice.

2. If you think we have incorrectly dismissed your request (that is, you believe you did address all of

the above listed items in your request), you may request a reconsideration of this dismissal by a

Qualified Independent Contractor (QIC). Your request must be received by the QIC at the address

below within 60 days of receipt of this letter. In your request, please explain why you believe the

dismissal was incorrect. The QIC will not consider any evidence for establishing coverage of the

claim(s) being appealed. Their examination will be limited to whether or not the dismissal was

appropriate. Please send your request to:

<INSERT QIC ADDRESS>

Sincerely.

NAME, TITLE

MAC NAME

(End) EXHIBIT 2

(Start) EXHIBIT 3:

MONTH, DATE, YEAR

APPELLANT NAME MEDICARE NUMBER OF

ADDRESS BENEFICIARY:

CITY, STATE ZIP

CONTACT

INFORMATION:

If you have questions, write or

call:

MAC Name

Address

City, State Zip

Telephone number

RE: <Include claim identifier or appeal number>

Dear <Appellant’s Name>:

This letter is in response to your appeal request (also known as a redetermination) that

was received in our office on <INSERT DATE>. The redetermination was requested for

dates of service <INSERT DATE(S)>. The initial determination for the items/services in

dispute was issued on <INSERT DATE OF RA/MSN>.

Your redetermination request has been dismissed because the date(s) of service in

question is/are past the time limit to file a request for a redetermination. A

redetermination request must be received in our office within 120 days of the date of

receipt of the initial determination date on the Medicare Remittance Advice or the

Medicare Summary Notice. The date of receipt of the initial determination is presumed

to be 5 days after the date of the notice unless there is evidence to the contrary.

Model

Redetermination

Dismissal Notice For

An Untimely Appeal

When we receive a request that has been filed late, we consider whether the appellant had

good cause for filing late. In special circumstances, we may allow additional time to file.

In this case, we did not find good cause for filing your request late.

If you disagree with this dismissal, you have two options:

1. You may request that we vacate our dismissal. We will vacate our dismissal

if you demonstrate good and sufficient cause for filing late. Your request to

vacate this dismissal must be received at the address above within 6 months of

the date of receipt of this notice.

2. If you think we have incorrectly dismissed your request (for example, you

believe you did file your request on time), you may request a reconsideration

of this dismissal by a Qualified Independent Contractor (QIC). Your request

must be received by the QIC at the address below within 60 days of receipt of

this letter. In your request, please explain why you believe the dismissal was

incorrect. Please note that the QIC will not consider any evidence for

establishing coverage of the claim(s) being appealed. Their examination will

be limited to whether or not the dismissal was appropriate. Please send your

request to:

<INSERT QIC ADDRESS>

Sincerely.

NAME, TITLE

MAC NAME

(End) Exhibit 3