Redetermination Requests and Submission of Documentation - Update
*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.
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)