An official website of the United States government
The Redetermination (First Level Appeal) Verification page allows you to verify the claims you selected for your redetermination request, as well as provide a text explanation or upload supporting documentation for your request.
The Claims included in the redetermination request section displays the claims that you selected for redetermination for the Case ID shown at the top of the page. The Type of Service (TOS) (Beneficiary and multi-factor authentication users only), Claim Control ID (ICN), Line #, Redetermination Reason, Total Charges, Reimbursement Amount, and Conditional Payment Amount will display for each claim.
Note: Certain information is masked unless you are the beneficiary, or you have logged in using multi-factor authentication.
Verify this list to ensure that it includes all claims you wish to submit for redetermination. Once you click Continue, you will confirm submission of the redetermination and you will be prevented from adding any additional claims to the current redetermination request.
To revise the list, click Previous to return to the Redetermination (First Level Appeal) Submission page. The claims you had previously selected will remain checked when you return to the Redetermination (First Level Appeal) Submission page.
Claims included in redetermination request
| Field | Description |
|---|---|
| TOS | (Beneficiaries and multi-factor authentication users only) 10 - Home Health Agency |
| Claim Control ID (ICN) | Claim Number (Internal Control Number) assigned to the claim by the Medicare processing contractor. |
| Line # | This number indicates one or more services that were billed on a single claim per Date of Service. |
| Redeterm. Reason | Reason selected for requesting a redetermination of this claim. |
| Total Charges | Amount billed by the provider. |
| Reimbursement Amount | Amount Medicare paid the provider. |
| Conditional Payment Amount | Amount due Medicare. |
Supporting Information & Documentation
After you have verified that the claims listed are those claims that you want to submit for redetermination, you may also provide supporting information by either entering a text explanation or uploading documentation (evidence) to support your redetermination request.
Note: Supporting documentation is only required to complete the review of your redetermination request, for any claims for which you didn't select a reason (or have a reason of "Other") on the Redetermination (First Level Appeal) Submission page.
Supporting Information (Text)
If you are providing an explanation for your request, you can enter up to 500 characters of free-form text in the text area provided.
Supporting Documentation
If you are uploading supporting documentation, it must be uploaded as a.PDF. To upload supporting documentation, click the Upload Documentation link to open the Redetermination (First Level Appeal) Documentation Upload page.
Notes:
For a list of documents and other information that would assist in processing your redetermination request, click the What Is This? link.
Click Previous to return to the Redetermination (First Level Appeal) Submission page. The claims you had previously selected will remain checked.
Click Continue to submit your redetermination and proceed to the Redetermination (First Level Appeal) Submission Confirmation page.
Click Cancel to cancel the redetermination request and return to the Case Information page. Any uploaded documents or free-form text that you entered will be lost.
Click Print this page to print a copy of this page for your records.
A federal government website managed and paid for by the U.S. Centers for Medicare and Medicaid Services.
7500 Security Boulevard, Baltimore, MD 21244