Tuesday, March 11, 2014

Redetermination Requests and Submission of Documentation - Update Medicare/Noridian 03/2014

Redetermination Requests and Submission of Documentation - Update

Providers requesting a redetermination must send the request in writing stating what they are appealing and reason why they are appealing. Providers can choose to send the written request on company letterhead or by completing CMS form 20027. Noridian recommends the use of the Interactive Redetermination Form that is downloadable from the Noridian website under the Forms section.

Redetermination Requests
*At a minimum, the request letter must contain the following information:
  • Beneficiary name;
  • Medicare health insurance claim (HIC) number;
  • The specific service(s) and/or item(s) for which the redetermination is being requested;
  • The specific date(s) of the service; and
  • The name and signature of the party or the representative of the party.
*These elements are included on the Noridian Interactive Form.
Send only one (1) request form or letter per beneficiary denial. When submitting a Redetermination, please attach the required documentation to support the appealable item(s). Redetermination requests should include *ALL medical documentation pertaining to the claim or line item. Reasonable and necessary denials must include a copy of the Advance Beneficiary Notice (ABN) signed by the beneficiary if available. Also attach a corrected UB04 form.
*Noridian suggests referencing the Medical Documentation Requirements found under Resources in the Appeals Section under Browse by Topic.

The following resources can be found on the Noridian website – Appeals section:
  • Medical Documentation Requirements – Alphabetized by Item/Service
  • Signature Requirements – Explanation of valid signature and alternatives
  • Inquiries and Solutions – Answers the common Redetermination and  Reconsideration questions including Recovery Auditor (RA) appeal questions
  • Appeals Not Necessary for Certain Reason Codes - A line item or claim rejection occurs, providers may adjust the claim through the normal claim submission process, if the change does not affect liability.
  • Remark Codes – Explains Remittance Advice Remark Codes (RARCs) that are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC)

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