Redetermination - The First Level of Appeal

310 - Redetermination - The First Level of Appeal (Rev. 2729, Issued: 06-21-13, Effective: 07-23-13, Implementation: 07-23-13) A party dissatisfied with an initial determination may request that the MAC review its determination. A redetermination is the first level of appeal after the initial determination on Part A and Part B claims. It is a second look at the claim and supporting documentation and is made by an employee that did not take part in the initial determination. If an initial determination is not made, there are no appeal rights on that claim (see §200.C for a list of actions that are not initial determinations and therefore do not have appeal rights). The reviewer must comply with, and is bound by, all applicable statutory and regulatory provisions. The reviewer may not overrule the provisions of the law or interpret them in a way different than CMS; nor may the reviewer comment upon the legality, constitutional or otherwise, of any provision of the Act, regulations, or CMS policy in the review determination. The reviewer is also bound by all CMS-issued policies and procedures, including CMS rulings, Medicare manual instructions, change requests, national coverage determinations, and local coverage determinations. The reviewer must consider the applicability of all CMS-issued policies and procedures to the facts of a given claim. The reviewer may not change the amount required to be paid under the Physician Fee Schedule.