Medicare Denied Your Claim? Here's How the Noridian Redetermination Process Works

When Medicare denies a claim, many practices either write it off or resubmit the same claim hoping for a different result. Neither is the right move.

Medicare has a structured appeals process with five levels. The first level — the redetermination — is handled directly by your Medicare Administrative Contractor (MAC). For providers in California, Hawaii, Nevada, and the Pacific Territories, that MAC is Noridian (Jurisdiction E for Part B).

Redeterminations are filed within the Noridian Medicare Portal, they're reviewed by a different Noridian employee than whoever made the initial determination, and the overturn rate on well-documented redeterminations is significant. Here's how to do it correctly.

What Is a Redetermination?

A redetermination is a formal request for Noridian to review a Medicare claim decision. It's not a resubmission — you're asking for a review of the original decision, not sending the same claim again.

When to file a redetermination:

• The claim was denied for medical necessity
• The claim was denied for missing or insufficient documentation
• The claim was denied for a coverage determination you believe is incorrect
• Payment was made but at an incorrect amount

When NOT to file a redetermination:

• The claim was denied for timely filing (a different process — a good cause exception request)
• The claim needs to be corrected and resubmitted (a corrected claim is not the same as an appeal)
• The claim was rejected by the clearinghouse before reaching Medicare (fix and resubmit)

Understanding which situation you're in matters — filing a redetermination when you should be filing a corrected claim wastes time.

The Deadline: 120 Days

You have 120 calendar days from the date of the Medicare Summary Notice (MSN) or Remittance Advice (RA) to file a redetermination. This is a hard deadline.

There is a process to request a late filing exception, but it requires documented good cause — don't rely on it. Build your AR review process to catch Medicare denials well within the 120-day window.

How to File a Redetermination Through the Noridian Portal

Step 1 — Log in to the Noridian Medicare Portal

Go to noridianmedicareportal.com. You'll need an active NMP account linked to your provider NPI and PTAN. If your billing team doesn't have portal access, setting that up is the prerequisite.

Step 2 — Navigate to the Redetermination Section

From the dashboard, select Claim Status and locate the denied claim using:

• Patient Medicare number (HICN or MBI)
• Date of service
• Claim number (from the RA)

Once you've pulled up the claim, select File a Redetermination (or navigate via the Redetermination/Appeals section depending on your portal view).

Step 3 — Complete the Redetermination Form

The portal guides you through a structured form. You'll provide:

• Beneficiary information: Name, Medicare ID, date of birth
• Claim information: Claim number, date of service, billed amount, denied amount
• Reason for redetermination: Select the applicable reason from the dropdown. For clinical denials, this is typically "Medical Necessity" or "Insufficient Documentation"
• Statement of issues: A clear, concise explanation of why the denial was incorrect. This is the most important part — write specifically, not generically

Step 4 — Attach Supporting Documentation

Documentation is what wins or loses a redetermination. Attach everything relevant:

For medical necessity denials:

• Relevant portions of the clinical documentation (office notes, procedure notes, diagnostic reports)
• Any applicable clinical guidelines supporting the service
• Prior authorization if it was obtained
• Physician attestation statement if the documentation needs clarification

For documentation denials:

• The complete note that was missing or flagged as insufficient
• Addenda with the treating physician's attestation if records were amended

For coverage denials:

• The applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD) and how your claim meets the criteria
• ICD-10 diagnosis codes with supporting clinical documentation

Do not attach more than is relevant — a focused, well-organized submission is more effective than a 40-page document dump.

Step 5 — Submit and Document

Submit the redetermination and record:

• Submission date
• Claim number
• The issue ID or tracking number the portal assigns
• What documentation was attached

Set a follow-up reminder for 45 days from submission — Noridian has 60 days to render a decision, but most decisions come faster. If you haven't received a determination by day 45, check the portal for status.

What Happens After You File

Noridian assigns the redetermination to a reviewer who was not involved in the original determination. They review your submission, the original claim, and the applicable coverage policy.

You'll receive one of three outcomes:

• Fully favorable: The denial is overturned. Medicare will reprocess and pay the claim.
• Partially favorable: Part of the denial is overturned. Some payment is issued.
• Unfavorable: The denial is upheld.

If unfavorable, the next step is a Qualified Independent Contractor (QIC) Reconsideration — the second level of the Medicare appeals process. The QIC is a contractor independent of Noridian, and the standard of review is fresh.

What Makes a Strong Redetermination

Be specific about the legal or clinical basis for your appeal. "The patient needed this service" is not a legal argument. "The clinical documentation supports medical necessity under Noridian LCD L33626 — the patient meets criteria [X] and [Y] as documented in the enclosed visit note" is.

Make it easy for the reviewer. Reference the specific LCD or NCD. Point to the exact lines in the clinical notes that support medical necessity. Don't make the reviewer search.

Use physician attestation strategically. If the documentation is genuinely complete but the initial reviewer missed something, a brief attestation from the treating physician confirming the clinical necessity can be decisive.

Don't rehash the original claim. The reviewer has the claim. Your job is to explain why the denial was incorrect — not to re-describe what happened at the visit.

A Note on Redetermination Volume

If you're filing redeterminations on the same denial reason repeatedly for the same CPT code, the problem isn't in the appeals process — it's upstream. A pattern of medical necessity denials on a specific procedure usually means the clinical documentation protocol needs updating to consistently meet the LCD criteria.

Fix the documentation workflow. The appeals are a recovery mechanism, not a substitute for compliant billing.

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Dealing with Medicare denials and not sure how to handle them? Talk to our billing team — we handle Noridian redeterminations and work directly in the portal to recover denied Medicare claims.