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Last Modified: 4/16/2024 Location: FL, PR, USVI Business: Part B

Appeal tips: Documentation to include with your Part B redetermination request

When submitting your Part B redetermination request, make sure to submit the appropriate supporting documentation for the patient's claim(s) in question so that we can consider all of the facts supporting your case. If supportive documentation is not submitted, your redetermination will be conducted using information in our possession.
Contractors have also been instructed not to request documentation from a provider or supplier for a State-initiated appeal. If additional documentation is needed, contractors should request that the submitter of the appeal (i.e., the State or the party authorized to act on behalf of the Medicaid State Agency) obtain and submit necessary documentation within 120 days of the initial determination.
Please remember that providers/suppliers, Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency are responsible for submitting documentation, if any, that supports the contention that the initial determination was incorrect under Medicare coverage and payment policies. This documentation should be supplied with the appeal request or at the request of the contractor. Failure to submit requested documentation in a timely manner may result in processing delays.
Please make sure all copies of documentation include the patient's name and are complete, legible, and contain both sides of each page, including page edges. Complete copies should include specific records to support the services on the claim(s) you are appealing and would include, as applicable, the following documents (not all-inclusive list):
Physician progress notes
Physician orders
Nurses' notes
Medication records
Graphic reports
Operative reports
Pathology reports
Consultant notes
All laboratory reports
Diagnostic test results (regardless of where they are performed)
History and physical notes
Hospice records
Home health progress notes
Certificate of medical necessity
Skilled nursing facility records
Ambulance records
Emergency room records
above list may be used as a guideline (not an all-inclusive list) when submitting documentation with your redetermination request.

Related links

instructions on completing and submitting our Medicare Part B Redetermination and Clerical Error Reopening Form, check out the Tips and Tutorials section on our Appeals page.
Matters booklet MLN006562 Medicare Parts A & B Appeals Process external pdf file
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.