Redetermination
The first level of the Medicare claims appeal process, conducted by the MAC.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Denials & Appeals
- Primary sources
- 2
- Workspace handoff
- denial workbench →
Where this comes up
This is denial-workbench territory. A remit posts with a CARC/RARC, the biller decides whether to rebill, appeal, or write off, and the appeal packet has to cite the chart, the order, and the payer's own policy language. Recurring patterns trace back to an upstream workflow gap.
Full definition
What it is in practice
Per 42 CFR Part 405, the Redetermination request must be filed within 120 days of the initial determination, decided within 60 days, with no minimum amount-in-controversy.
How it shows up in your practice
This is where the volume lives. Build a redetermination letter template by denial type. The 120-day clock and 60-day decision frame need automated tracking.
Sources
- CMS — Medicare Claims Appeals Processhttps://www.cms.gov/medicare/appeals-grievances/fee-for-service/original-medicare-ffs-appeals
- 42 CFR Part 405 — Medicare claims and appealshttps://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405
Use the redetermination template in the Denial Workbench
Open denial workbench →Related terms
- Denials & AppealsMedicare Appeals LevelsThe five-level Medicare appeals process: Redetermination, Reconsideration, ALJ Hearing, Medicare Appeals Council, and Federal District Court.
- Denials & AppealsReconsiderationThe second level of the Medicare claims appeal process, conducted by a Qualified Independent Contractor (QIC).
- Denials & AppealsDenial ManagementThe end-to-end workflow of identifying, categorizing, appealing, and preventing claim denials.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryMedicare Appeals LevelsThe five-level Medicare appeals process: Redetermination, Reconsideration, ALJ Hearing, Medicare Appeals Council, and Federal District Court.
- GlossaryReconsiderationThe second level of the Medicare claims appeal process, conducted by a Qualified Independent Contractor (QIC).
- GlossaryDenial ManagementThe end-to-end workflow of identifying, categorizing, appealing, and preventing claim denials.
- GlossaryALJ HearingThe third level of the Medicare claims appeal process, before an Administrative Law Judge at OMHA.
- GlossaryAppeal LetterThe written request to a payer to reconsider a denied or partially-paid claim.
- GlossaryAudit DefenseThe organized process of preparing for and responding to a payer or government audit.
- GlossaryExtrapolationThe statistical projection of overpayment findings from a sample of claims to a larger universe of claims, used in many Medicare audits.
- BillingHow to Appeal an Insurance Denial: Step-by-Step GuideClaim denied? Step-by-step appeal process with payer deadlines, denial code fixes, appeal letter template, and escalation options.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.