Redetermination Time Limit: Reminder


It is critical that you submit requests for redetermination within the time limits established by the Centers for Medicare & Medicaid Services. These time limits can only be extended in certain circumstances.

Redetermination requests must be submitted within 120 calendar days from the date of receipt of on the initial determination notice. The initial determination notice is the Electronic Remittance Advice (ERA) or Standard Provider Remittance Notice (SPR):

  • From the first submission of that service
  • Does not include any service rejected as a billing error (remark code MA130)
  • If the date shown on your ERA or SPR is more than 120 days from the current calendar date, the time frame for requesting a redetermination has ended

Example

Date of Initial Determination
(From the ERA or SPR)
Current Calendar Date
Elapsed Days
Redetermination Rights
Redetermination Request Must be Received by This Date
05/15/2020
10/15/2020
153
No
09/17/2020
08/14/2020
10/14/2020
61
Yes
12/17/2020

Note: CMS allows a grace period of an additional five days beyond the time limit of 120 days from the date of the initial notice. The dates above include the five-day extension. This allows a five-day window for mail delivery. We may allow for additional time if you can provide documentation that mail delivery took longer than five days.

Extension of Time Limit for Filing a Request for Redetermination
If an appeal request is filed late, the time period may be extended for filing a redetermination if you can demonstrate good cause. These extensions are not routinely granted, so it is important to provide supporting documentation if you are requesting an extension of this time limit.

References

  • CMS Publication 100-04 (PDF, 790 KB), Chapter 29, § 240 
  • Use the Denial Resolution Tool to research denials. This tool provides resources that will help you submit the claim correctly and completely the first time. Access the tool right from the home page in the Tools section. 

Remember: Claims rejected as unprocessable (billing errors, indicated with remark code MA130) have no appeal rights and cannot be submitted as Redetermination requests. The best way to handle these errors is to correct and resubmit the claim.





Last Updated: 12/29/2020