Note: MACs do not process claim corrections involving minor errors and omissions through the appeals process. The contact information for each MAC can be found using the following link: /Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs#MapsandLists. Most MACs allow electronic submission of appeals through their website. Check the MAC website for more information on how to file appeals. The redetermination request must be sent to the MAC that made the initial claim determination (this information is on the MSN and the RA). A minimum monetary threshold on the claim is not required to request a redetermination. The appellant should include with their redetermination request any and all documentation that supports their argument against the previous decision. An explanation of why the appellant disagrees with the contractor's determination.Name of the party, or the representative of the party.Specific service(s) and/or item(s) for which a redetermination is being requested.Make a written request containing all of the following information:.Fill out the form CMS-20027 (available in “Downloads” below).There are 2 ways that a party can request a redetermination: The notice of initial determination is presumed to be received 5 calendar days after the date of the notice, unless there is evidence to the contrary.Ī redetermination must be requested in writing. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file a redetermination request. Requesting a RedeterminationĪn initial determination decision is communicated on the beneficiary's Medicare Summary Notice (MSN), and on the provider's, physician's and supplier's Remittance Advice (RA). A redetermination is a review of the claim by Medicare Administrative Contractor (MAC) personnel not involved in the initial claim determination. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.Any party to the initial claim determination that is dissatisfied with the decision may request a redetermination. Availity provides administrative services to BCBSTX. Be sure to include your contact information, Tax ID number, and Billing NPI.Īvaility is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Also see the Claim Status Tool User Guide for help with obtaining enhanced claim status online.Įmail our Provider Education Consultants for assistance. *Note: Uploaded attachments may take minutes to hours before they are viewable in the request.įor details, refer to the instructional Claim Reconsideration Requests User Guide. view uploaded documents after attached to the request*.generates a Dashboard view of claim reconsideration request activity.view and print confirmation and decision.upload of supporting documentation with submission.Using this new online offering allows the following: The claim reconsideration option should be used to inquire on a previously processed claim. We encourage you to begin using the new method for claim reconsideration requests now, as the Claim Inquiry Resolution (CIR) tool will be modified to only accommodate certain claim scenarios. Please note: This electronic option is not currently available for Medicare Advantage or Texas Medicaid claims. This method of inquiry submission is preferred over faxed/mailed claim disputes to BCBSTX, as it allows providers to upload supporting documentation and monitor the status – all online.Ī Claim Reconsideration is a request to review and/or reevaluate a claim that has been finalized. The Claim Reconsideration request option allows providers to electronically submit claim reconsiderations for situational finalized claim denials (including BlueCard ® out-of-area claims), using Availity ® Essentials Dispute Claim capability, which is anchored off the enhanced Claim Status tool.
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