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
The above list may be used as a guideline (not an all-inclusive list) when submitting documentation with your redetermination request.
Related links
- For 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.
- MLN Matters booklet MLN006562 Medicare Parts A & B Appeals Process
- IOM 100-04 Medicare Claims Processing Manual, Chapter 29, Section 310