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September 2, 2015 – Revised: 01.10.20

Completing the Medicare Part A Jurisdiction 15 Redetermination Request Form

We are noticing a spike in Medicare Part A Redetermination Request forms being submitted for Appeals review that are not accurate and/or fully complete. This is causing unnecessary dismissals and impacting how quick we can get an Appeal response back to you. In our effort to ensure a timely review without rework we want to share the following best practices.

As a reminder, providers only have 120 days from the date a claim and/or adjustment finalizes to submit an appeal.

  • Complete the form in its entirety. Empty or blank sections will result in a dismissal.
  • Requestor's Name – The requester must print his name or a provider contact name in each appropriate section. The omission of information in either section will result in a dismissal.
  • Overpayment appeal – Are you appealing an overpayment? If so, don't forget to check the appropriate reviewer box (e.g., MR, CERT, RAC, etc.).
  • Adjustments – If you are appealing adjustment enter the adjustment DCN, not the original claim DCN. This information is vital.
  • Rationale for the appeal – Be concise when explaining the reason for the appeal. This action assists the reviewer in successfully completing the appeal.
  • Claim in an 'S' or 'T' status location – The claim has not finalized; therefore, an appeal cannot be requested.
  • Denial 56900 – Non receipt of records – ADR documentation not returned
    • Within 120 days of the remittance advice – submit records to the Medical Review (MR) department as a reopening. (If the Appeals department receives the ADR documentation within 120 days of the remittance advice, it's rerouted to the MR department, which delays the processing of your request.) MR contact information is available under Contact Information on the Part A CGS website.
    • More than 120 days from the remittance advice – submit records to the Appeals department as a redetermination request.

Did you know you can now submit redeterminations via the myCGS portal? This electronic process is convenient and an immediate solution in meeting the 120-day time limit for submitting an appeal. Why use snail-mail, when you can submit a redetermination electronically? Find out more on the myCGS portal website under myCGS Functions.

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