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Redetermination Decision Tree Instructions

Redetermination Decision Tree Instructions. Click the button to return to the previously viewed slide. Click the button to return to the beginning of the decision tree. Click the button to return to these instructions Hit the Esc key to exit the decision tree.

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Redetermination Decision Tree Instructions

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  1. Redetermination Decision Tree Instructions • Click the button to return to the previously viewed slide. • Click the button to return to the beginning of the decision tree. • Click the button to return to these instructions • Hit the Esc key to exit the decision tree Get Started!

  2. Redetermination Decision Tree Answer the following questions to determine if you need to file an appeal

  3. Does this claim relate to issues involving Medicare Secondary Payer? No Yes

  4. Please submit your request on the MSP form • Instructions for filing MSP request • Part A Instructions • Part B Instructions Still have questions? We can help!

  5. Do you agree with the claim determination? No Yes

  6. Please check the remarks on your remittance Does the phrase “Claim lacks information which is needed for adjudication” appear in the remarks section of your remittance? No Yes

  7. Please submit a new claim • Check the remittance advice remark code for assistance. To view lists of the current Medicare-specific reason/denial codes and the remark codes, visit the Washington Publishing Company (WPC) Web site at www.wpc-edi.com/codes • Please submit new claim with all required information. Still have questions? We can help!

  8. Have you previously received a redetermination decision on your claim? No Yes

  9. Was the denial a Timely Filing Denial? No Yes

  10. Timely Filing Denial Timely Filing Denials are not appealable through the Redetermination process. You may request a Reopening with documentation of your justification. • Click here for instructions on filing a Reopening Request Still have questions? We can help!

  11. Please Submit a Reopening Request • Click here for instructions on filing a Reopening Request Still have questions? We can help!

  12. Denial Stating You Need to File Electronically? Was the denial from a paper claim submission stating that you need to file electronically? No Yes

  13. Please file claim electronically • This is not an Appealable issue. Please file claim electronically. Still have questions? We can help!

  14. Was everything submitted correctly on the original claim? No Yes

  15. Did this cause a payment reduction on this or another claim? No Yes

  16. Was the denial caused by minor error or omission? No Yes

  17. Did you receive an Additional Documentation Request for your claim? No Yes

  18. Did you send the requested information? No Yes

  19. Send information requested • Please refer to your request for additional documentation and submit documentation according to the instructions on the ADR. Still have questions? We can help! Version 1.0

  20. Did your claim deny after submitting requested documentation? No Yes

  21. Select Type Denial Medical Necessity Statutory Exclusion Bundling Payment Amount

  22. Sample Questions No Yes

  23. No Action Necessary • No reopening or redetermination is necessary if payment was not reduced on this or another claim. Still have questions? We can help!

  24. Please submit a Reopening Request • You may file for a reopening within 1 year of claim determination date • Click one of the following for instructions on how to file a Reopening • Part A Instructions • Part B Instructions Still have questions? We can help!

  25. Please submit a Redetermination Request • You may file for a redetermination request within 120 days of initial determination date • Click below for instructions on how to file a Redetermination • Part A • Part B Still have questions? We can help!

  26. Not eligible for Appeal • No appeal is necessary if you agree with the initial claim determination. Still have questions? We can help!

  27. Statutory - Not Appealable • Items and services statutorily excluded from Medicare coverage are not appealable. Still have questions? We can help!

  28. Bundling - Not Appealable • Check MFSDB for filing instructions and submit a Reopening if filed incorrectly. Still have questions? We can help!

  29. Do you disagree with the CMS amount you were paid? No Yes

  30. Choose how the claim was priced Claim Priced by your Medicare Contractor Claim Paid Based on Medicare Fee Schedule

  31. No action necessary • Not appealable. Medicare contractors do not have discretion with regards to approved fee schedule amounts. Still have questions? We can help!

  32. Request a 2nd level appeal Please request a 2nd level appeal • Part A Instructions • Part B Instructions Still have questions? We can help!

  33. Contact us Contact our Provider Contact Center • Contact Us Webpage Still have questions? We can help!

  34. Sample Questions No Yes

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