Redetermination is which level of appeal in Medicare claims?

• A. The first level of appeal, in which a claim is reviewed by Medicare Area Contractor personnel different from the personnel who made the initial denial determination
• B. The second level of appeal
• C. The final CMS decision
• D. An administrative review with no appeal rights

Answer: (A)

Redetermination is the first level of appeal in Medicare claims. After an initial denial, the claim is reviewed by Medicare Area Contractor staff who were not involved in the original decision, providing a fresh, independent look. If the outcome isn’t resolved to the claimant’s satisfaction, the next step is reconsideration by a Qualified Independent Contractor, which is the second level. Higher levels involve a hearing before an administrative law judge, then review by the Medicare Appeals Council, and potentially federal court. The other options refer to later stages or to actions that aren’t formal appeals.