How to Request A Redetermination

Medicare Claims Processing Manual (Pub 100-04 Ch. 29 §310)

A "Redetermination," the first level of appeal, is an independent, re-examination of the claim and its supporting documentation by Cahaba staff who were not involved in the initial claim decision.

The redetermination request must be submitted within 120 calendar days from the date of the initial determination notice.

To request a redetermination, complete the CMS-20027, Medicare Redetermination Request Form, the Cahaba Medicare A Redetermination Request form, or submit a written request. Information provided in the written redetermination request letter will not be accepted as documentation unless it is substantiated in the medial record. Documentation in the medical record must be sufficient to show the services were covered under the Medicare benefit. Refer to the Medical Record Documentation Web page for information about submitting documentation with an appeal request. Note: Please do not send us your documentation in a binder, with tabs, or with multiple staples.

Written requests should include the beneficiary name, Medicare health insurance claim number (HICN), name and address of provider of services, dates of service for which the initial determination was issued, which item or service is being appealed, and the provider/representative’s signature.

Redetermination requests should be mailed to the Appeals address found on the Write Us Web page.

Tracking Your Appeal Request

To determine if Cahaba has received your appeal request, refer to the Online Reports View section of the FISS Reference Guide.

Redetermination Decision—Time Frame for Completing

Cahaba has up to 60 days from the date the appeal request is received to make a decision on a redetermination. Please do not contact us about your request until that time has passed. You will be notified once a decision has been made. Refer to the Notice of Redetermination Decision Web page for information about how you receive notification of Cahaba’s decision.