A denied Medicare claim does not end with the denial letter. Under 42 CFR 405.942, your practice has a 120-day window from the date it receives the notice of the initial determination to file a redetermination, the first level of the Medicare appeals process and the one most practices treat as a formality. It is not a formality. The redetermination is where the evidentiary record gets built, and under CMS's own evidence rule, whatever your practice does not submit at this level can be barred from consideration at every level that follows, including the reconsideration that stands between your practice and recoupment.
The 120-Day Filing Window
The clock starts when your practice receives, not when the Medicare Administrative Contractor mails, the notice of initial determination. Under 42 CFR 405.942(a), a redetermination request must be filed within 120 calendar days of that receipt date, and the regulation presumes receipt occurs 5 calendar days after the date on the notice unless the practice can show otherwise. The initial determination can come from a routine claims edit, a RAC audit finding, or an SMRC or CERT sample review. If the 120 days lapse, 405.942(b) allows the contractor to extend the deadline only on a showing of good cause, such as a documented failure to receive the notice, a serious illness, or incorrect guidance from the contractor itself. Good cause is not automatic, and the contractor decides it on the record the practice submits.
What a Redetermination Request Must Include
A redetermination request is a written submission, not a phone call or a marked-up remittance advice. Under 42 CFR 405.944(b), it must identify the beneficiary by name and Medicare number, the specific service or item in dispute and its date of service, and the name of the party or representative making the request. CMS Form 20027 satisfies the requirement, but any written submission containing the same elements is acceptable. The stronger filings go further and attach the medical record, any documentation previously requested in an additional documentation request, and a narrative explaining why the denial was wrong under the applicable coverage rule, whether a local coverage determination or the statute itself.
The Evidence Lock-In Rule
Most practices treat the redetermination as a box to check before the real appeal at the Administrative Law Judge hearing. That approach forfeits the practice's strongest chance to win, and it can forfeit the evidence itself. Under 42 CFR 405.966(b), absent good cause, evidence a practice does not submit by the time the redetermination decision issues cannot be considered at the reconsideration level that follows, the appeal to a Qualified Independent Contractor. A practice that holds back its strongest documentation, an addendum note, a corrected order, evidence rebutting an extrapolated overpayment demand, for a later stage may find that stage refuses to look at it. The contractor must decide the redetermination within 60 calendar days of a timely filed request.
Evidence your practice does not submit before the redetermination decision issues may never be considered again.
Why Early Legal Counsel Is Critical
It is critical that physician practices promptly retain experienced healthcare defense counsel upon receiving a Medicare initial determination, an additional documentation request, or an audit finding from a RAC, SMRC, or CERT contractor. Early legal intervention can protect the practice's rights, build the evidentiary record before the redetermination deadline closes, avoid conceding points that cannot be recovered at a later appeal level, and preserve the defenses available on reconsideration and beyond. Delaying representation until the reconsideration stage can mean arguing the case without evidence the redetermination record should have carried forward.
How Health Law Alliance Can Help
Health Law Alliance represents physicians and physician practices in Medicare redeterminations arising from RAC, SMRC, CERT, and Medicare Administrative Contractor audits, as part of the firm's Medicare audit defense practice. The firm builds the evidentiary record from the day an initial determination issues, not after the redetermination decision closes the door on new evidence, and frames every filing around the specific denial reason the contractor cited. If your practice has received a Medicare claim denial or an audit finding, contact us for a free, confidential consultation.
