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If you disagree with the initial decision from your plan (also known as the organization determination), you or your representative can ask for a reconsideration (a second look or review). You must ask for a reconsideration within 60 days of the date of the organization determination.
The first level of an appeal, a Redetermination, is a request to review a claim when there is a dissatisfaction with the original determination. A Redetermination is an independent re-examination of an initial claim determination.
Yes, the claims reopening process is specifically for simple corrections or omissions that do not require additional documentation. More complicated issues must be submitted in writing. The redetermination form is used for the first level appeal and the reconsideration form for the second level appeal.
Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).
There are 2 ways to submit a reconsideration request. Fill out a Medicare Reconsideration Request Form. [ PDF, 180 KB] Submit a written request to the QIC that includes: Your name and Medicare number. The specific item(s) or service(s) for which youre requesting a reconsideration and the specific date(s) of service.
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Fill out a Redetermination Request Form [PDF, 100 KB] and send it to the company that handles claims for Medicare. Their address is listed in the Appeals Information section of the MSN. Or, send a written request to company that handles claims for Medicare to the address on the MSN.
Level 1: Redetermination The Medicare Administrative Contractor you appeal to must issue a decision within 60 days of receiving your request.
Appeals Level 2: Qualified Independent Contractor (QIC) Reconsideration. A QIC is an independent contractor that didnt take part in the level 1 decision. The QIC will review your request for a reconsideration and make a decision.

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