Contractor Redeterminations or Reconsiderations in Assignment

120.5 - Contractor Redeterminations or Reconsiderations in Assignment Cases Conducted at the Request of Either the Beneficiary or the Assignee (Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07) In every appeal where the limitation on liability provision is applicable, the redetermination consists of two stages. The first stage is a new, independent and critical reexamination of the facts regarding the coverage issue. If the original decision regarding coverage was appropriate, the second stage is the decision whether to limit the liability of the beneficiary and, if so, whether to also limit the liability of the provider, practitioner, or supplier. Redeterminations in assignment cases are conducted at the request of either the beneficiary or the assignee. Frequently, the redetermination request is received from only one of the parties, either the provider/physician/supplier or the beneficiary, and the only notice to the other party that a redetermination has been requested is a copy of the determination, i.e., after the fact. In a limitation on liability case, the parties may have adverse interests in the limitation on liability decision, since a provider, practitioner, or supplier may seek to show reason why the beneficiary’s liability should not be limited in order to be able to collect his/her fee from the beneficiary. Therefore, when the contractor receives a request for a redetermination, it sends a notice that a request has been filed to the other party to the redetermination indicating that that party may submit additional evidence. This is necessary to satisfy the statutory requirement that both parties be informed of their rights and privileges in the appeal process.