Medicare Redetermination (First-Level Appeal)
A Medicare redetermination is the first level of the five-level Medicare fee-for-service appeals process. A provider or beneficiary who disagrees with an initial claim determination requests a fresh review by the Medicare Administrative Contractor, and must file within 120 days of the remittance advice date.
- Appeal level
- Level 1 of 5 (Medicare FFS)
- Reviewed by
- Medicare Administrative Contractor
- Filing deadline
- 120 days from remittance advice
- Form
- CMS-20027 or written request
What is a Medicare redetermination?
A redetermination is the first of five levels in the Medicare fee-for-service appeals process. When Medicare denies a claim or pays less than you believe is due, you ask the Medicare Administrative Contractor to look again. The reviewer is someone not involved in the original decision, so it is a genuine second look, not a rubber stamp of the first.
Redeterminations are the workhorse of Medicare appeals; most disputes, especially medical necessity denials with strong documentation, are resolved here.
How and when do you file a redetermination?
You have 120 days from the date you receive the remittance advice. File on form CMS-20027 or in writing, and attach the evidence that supports the claim.
- Identify the specific denial reason and the policy it cites.
- Gather the medical record and any supporting ABN or authorization.
- Map the documentation to the coverage criteria in the LCD or NCD.
- Submit to the MAC within 120 days of the remittance date.
What are the five levels of Medicare appeal?
Example: a Part B denial for a specialized lab test is upheld at redetermination, so the practice escalates to reconsideration, and if needed beyond. Knowing the ladder prevents deadlines from lapsing between levels.
| Level | Decided by | Deadline to file |
|---|---|---|
| 1. Redetermination | MAC | 120 days |
| 2. Reconsideration | Qualified Independent Contractor | 180 days |
| 3. ALJ hearing | Administrative Law Judge | 60 days |
| 4. Appeals Council | Medicare Appeals Council | 60 days |
| 5. Judicial review | Federal district court | 60 days |
Frequently asked questions
It is the first level of the Medicare fee-for-service appeals process. When a claim is denied or paid at an amount you dispute, you ask the Medicare Administrative Contractor for a redetermination, a complete re-review by staff not involved in the original decision. It is the entry point before any higher appeal level can be pursued.
120 days from the date you receive the Medicare remittance advice (the initial determination). The date of receipt is presumed to be five days after the remittance date unless proven otherwise. Missing the 120-day window generally forfeits appeal rights, so redeterminations should be triaged and filed promptly, not held.
The second level is reconsideration by a Qualified Independent Contractor, filed within 180 days. Above that are an Administrative Law Judge hearing (with an amount-in-controversy requirement), Medicare Appeals Council review, and finally federal district court. Each level has its own deadline and threshold, so track them from the first denial.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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