1st Level of Appeal – Redetermination
- Claims Processing Manual, Pub. 100-04, Chapter 29 – Appeals and Claims Decisions
- Original Medicare (Fee-for-service) Appeals
- CMS Medicare Part A & B Appeals Process
Physicians, suppliers, and beneficiaries have the right to appeal claim determinations made by MACs. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by MACs are governed by the Centers for Medicare & Medicaid Services (CMS). As a MAC, CGS handles the first level of appeal, redetermination requests. There are five levels of appeal.
Redetermination Form / Job Aids
- CGS Jurisdiction 15 Redetermination Request Form
- Completing the Medicare HHH Jurisdiction 15 Redetermination Request Form
- Submitting Redetermination Requests
- Redetermination Submission Check-List
Time Limit for Filing Request |
120 days from the date of receipt of the notice of initial determination |
Monetary Threshold to be Met |
None |
Helpful Tips |
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The beneficiary or their representative may request an appeal on any service processed for them. Provider and Suppliers may appeal services for which assignment was accepted. For unassigned claims, providers/suppliers may act as the beneficiary's representative if the beneficiary signs an authorization statement (such as form CMS-1696). In addition, provider/suppliers may request a redetermination on an unassigned claim if Medicare B denied the service as not reasonable and necessary or the provider/supplier billed in excess of the Limiting Charge and the provider/supplier is required to refund any fees collected from the beneficiary.
Additional Resources:
Updated: 12.08.23