← Glossary · CMS & regulatory
Redetermination
A sponsor's review (appeal) of a coverage determination or at-risk determination. Standard: 7 calendar days; expedited: 72 hours.
Standard redeterminations must be notified no later than 7 calendar days after receipt, and expedited ones no later than 72 hours. The person who made the original coverage or at-risk determination may not conduct the redetermination. A denial for lack of medical necessity must be redetermined by a physician with appropriate expertise.
Source: CDAG protocol, Timeliness 1.8-1.9, p. 6; Processing of Coverage Requests 2.6, p. 12.