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Redetermination Request Form

This form may be used to request a redetermination for Medicare Part B services. A redetermination is the first level of the Medicare Appeals Process. All requests should be submitted within 120 days of the initial claim determination.

Appellants should attach any supporting documentation to their redetermination request. Contractors will generally issue a decision (either a letter or a revised remittance advice) within 60 days of receipt of the redetermination request.

Please be advised, CMS has instructed all contractors to no longer correct minor errors and omissions on claims through the appeals process. Please see MLN Matters Article SE0420 on the CMS Web site for more information.

Redetermination requests can be made, but are not limited to the following situations:

In order to process a Redetermination request, we also need the following pieces of information:

J15 — Part B Correspondence
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