Medicare redetermination form - appeal checklist for successful appeal.

Redetermination Request Form Checklist

• Review the Standard Paper Remittance (SPR) or Medicare Electronic Remittance Advice (ERA) for the claim(s) you are requesting a Redetermination on. Is the ERA or SPR from Noridian Administrative Services?

            If not, please submit the request for Redetermination to the appropriate Durable Medical Equipment Medicare Administrative Contractor (DME MAC) identified on the ERA or SPR.

• Were the claim(s) in question denied with an ANSI code which is appealable? Does the ERA or SPR indicate a remittance advice remark code of MA01, this indicates appeal rights are available? If appeal rights are not available were the claim(s) denied as unprocessable? If so, you must correct and resubmit the claim(s).

• Is your denial due to a minor clerical error or omission (i.e., units of service, service dates, HCPCS coding, diagnosis codes, etc.)? If so, please submit a Reopening request. Reopenings can be submitted in writing through the mail, by fax or through the telephone reopening line at 1-888-826-5708. A written reopening request form is available on our Web site at: https://www.noridianmedicare.com/dme/forms/docs/nas_reopen_dme.pdf

• What was the date of the final determination indicated on the ERA or SPR? Have more than 120 days lapsed since the final determination? If more than 120 days have lapsed since the final determination you will need to provide “good cause” documentation to explain the late filing of your request for redetermination.

• Have you reviewed all of the information listed above? If so, you are Now ready to file a Redetermination request. Please submit the request to:

                 Noridian Administrative Services
                 PO Box 6727
                 Fargo ND 58108-6727

Reminder: The Medicare Redetermination Request form and the CMS form 20027 are not required but are recommended. However, if you decide not to utilize either of these suggested forms you must submit at minimum the following elements:

• Beneficiary’s Name
• Beneficiary’s Medicare HICN
• Specific service(s) and/or item(s) for which the redetermination is being requested and the specific date(s) of service, and
• First and last name and signature of the person filing the request

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