Redeterminations

The first level appeal is referred to as a redetermination. All redeterminations must be completed within 60 days of receipt.

A party dissatisfied with an initial claim determination may request a redetermination. A redetermination is a second look at the claim and supporting documentation. If an initial determination on a claim has not been made, there are no appeal rights on that claim. Suppliers should wait to file a redetermination until they receive their Medicare remittance notice which provides the claim determination. A redetermination is a new, independent, and critical re-examination of a claim. It is conducted by re-examining the information in the file and any additional documentation submitted with the request for a redetermination.

The denial on a duplicate claim line item is not a denial of service; there are no appeal rights on the duplicate submission. Appeal requests on duplicate claim denials will be treated as inquiries—not as an appeal. Suppliers must request an appeal on the original denial (i.e., the first claim submitted). The DME MAC will look at the first claim submission to determine whether the request was filed timely. The supplier may submit a fully completed Jurisdiction B DME MAC Redetermination Request Form when requesting a redetermination. If this form is not used, the supplier’s request must contain all the following information:

• Beneficiary’s name
• Beneficiary’s Medicare Health Insurance Claim number (HICN)
• Specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
• Name and signature of the person filing the request

Incomplete requests will be dismissed with an explanation of the missing information. Suppliers will be instructed to resubmit the request with all of the missing information.

When filing an appeal, a separate request is not required for each procedure code on the claim. All appeal requests for a specific beneficiary or claim number can be combined on one request.

Submit redetermination requests to the following address:

Jurisdiction B DME MAC
Redeterminations
P.O. Box 6036
Indianapolis, Indiana 46206-6036

In situations where a provider, supplier, or beneficiary requests a redetermination and the issue involves a minor error or omission, the DME MAC will treat the request as a request for a reopening.

Reconsideration

The second level of appeal is the reconsideration request. Section 1869 of the Social Security Act (the Act) entitles any individual dissatisfied with the contactor’s redetermination to file a request for reconsideration. This request must be submitted within 180 days of receipt of the redetermination. In accordance with Section 1869(c) of the Act, (the item or service has been deemed not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member) reconsiderations are to be processed within 60 days by entities called qualified independent contractors (QICs). When a claim is denied on the basis of Section 1862(a)(1)(A) of the Act, the QIC reconsideration will consist of a panel of physicians and other health professionals. When the panel reviews services or items rendered by a physician or ordered by a physician, the panel will consist of at least one physician.

The QIC for all Part B durable medical equipment (DME) appeals is RiverTrust Solutions, Inc.

Reconsiderations should be filed to the QIC on the Jurisdiction B DME MAC Reconsideration Request Form. Reconsideration requests should be mailed to the following address:

RiverTrust Solutions, Inc.
P.O. Box 180208
Chattanooga, Tennessee 37401-7208

The date of filing, for requests submitted in writing, is defined as the date received by the QIC in their corporate mailroom. If the party has filed the request in person with the QIC, the filing date is the date of filing at such office, as evidenced by the receiving office’s date stamp on the request. If the party has mailed the request for reconsideration to CMS, the Social Security Administration, Railroad Retirement Board office, or another government agency in good faith within the time limit, and the request did not reach the appropriate QIC until after the time frame to file a request expired, the QIC considers good cause for late filing. (Refer to the CMS Internet-Only Manual [IOM] Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240 for additional information relating to good cause.) Likewise, if the request is filed with CMS, Social Security Administration, Railroad Retirement Board office or another government agency in person, the QIC considers good cause for late filing.

Note: Any additional evidence should be submitted with the request for reconsideration and prior to the reconsideration decision being issued. If all evidence is not submitted piror ot the issuance of the reconsideration decision, the supplier will not be able to submit any new evidence to the administrative law judge for further appeal unless they can demonstrate good cause for withholding the evidence from the QIC.

The QIC may extend the period for filing if it finds the appellant had good cause for not requesting the reconsideration timely. (Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240 for additional information relating to good cause.) In order for good cause to be considered, the appeal request must be in writing. If the QIC finds that the appellant did not have good cause for not requesting reconsideration on time, it may, at its discretion, consider reopening.

Note: There is no monetary threshold to be met when filing a reconsideration request to the QIC.

Administrative Law Judge

The third level of appeal is an administrative law judge (ALJ) hearing. A hearing before an ALJ of the Social Security Administration may be requested if the appellant is not satisfied with the QIC determination. The ALJ hearing must be requested in writing within 60 days from the date of the QIC’s decision. The request must specifically state that an ALJ hearing is desired and the request must be signed. Suppliers should submit ALJ hearing requests to the following address:

Administrative Law Judge
Office of Medicare Hearing and Appeals – BP Tower
200 Public Square, Suite 1300
Cleveland, Ohio 44114

Note: There must be at least $120 in controversy to request an ALJ hearing on or after January 1, 2008.

Departmental Appeals Board Review

If an appellant is dissatisfied with the ALJ decision, they may contact CMS directly for an appeals council review. The appeals council review must be requested within 60 days of the date of the ALJ decision.

Federal Court Review

If an appellant is still dissatisfied with the decision and the amount in controversy exceeds $1130 prior to January 1st, 2008, or on or after January 1st, 2008 the amount in controversy exceeds $1180, they may request a hearing before the federal court.