When to File an Appeal

If you are dissatisfied with how your Medicare Part B claims have processed, you can request a first-level appeal (redetermination).

A redetermination follows an initial determination of a claim.

A redetermination (first-level appeal request) cannot be submitted for claims that have not completed processing (pending claims vs finalized claims). Providers should only submit a redetermination request once they have received a remittance notice for the claim or an overpayment demand letter for a previously paid claim. You can check the IVR or our eServices self-service portal to determine if your claim has finalized.

When the redetermination involves an overpayment situation, you should attach a copy of the overpayment demand letter and any spreadsheet or claims listing with your request.

The Appeals department has seen an increase in responses to requests for medical records being submitted with a redetermination request form or via our portal as a redetermination request for claims that have not yet finalized. Responses to record requests should not be submitted with a redetermination request form. These should be responded to using the Medical Review ADR Response Cover Sheet, attaching the request letter, and sent to the address provided in the Medical Review request letter.

Claims that are rejected (MA-130 on your remittance notice) cannot be appealed. You must correct the error and submit a new corrected claim to be processed.

All redetermination requests must be filed within 120 days after the date of receipt of the notice of the initial determination (the notice of initial determination is presumed to be received five days after the date of the notice unless there is evidence to the contrary).