Medicare Compliance & Reimbursement

Question: We are getting really close to the 120-day deadline to submit a redetermination to Medicare for a claim decision we disagree with. Is there any wiggle room on that deadline or can we ask for an extension?

Texas Subscriber

Answer: So, you are correct that the Centers for Medicare & Medicaid Services (CMS) gives providers filing a redetermination — the first level of the Medicare appeals process — 120 days from the date of the initial determination notice to submit a request. However, “CMS allows a grace period of an additional five days beyond the time limit of 120 days from the date of the initial notice,” particularly for providers submitting a redetermination via mail delivery, notes Part B Medicare Administrative Contractor (MAC) Palmetto GBA on its webpage.

In certain cases, CMS will permit practitioners extra time. It’s rare, however, and comprehensive claims documentation is required when requesting the redetermination extension, Palmetto says. “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.”

Heads up: Another current problem plaguing providers is incomplete redetermination forms, which doesn’t automatically necessitate the need for an extension. For example, Part B MAC CGS issued an alert that it is seeing an uptick in redetermination request errors, according to an Oct. 10 alert. “Many redetermination requests submitted through myCGS are dismissed because the form is not completed correctly; digits of the Internal Control Number (ICN) are transposed, codes and modifiers added to the form are not on the original claim/CGS remittance advice, etc,” CGS says. “These errors occur because myCGS users oftentimes accessed the Redeterminations form from the FORMS tab instead of the CLAIMS tab.”

If your requests aren’t getting processed and your appeals continually get dismissed, it could be a form issue. Check with the MAC in your jurisdiction for advice on the tools and tips available for redetermination success.