Initial determination
A Medicare contractor's decision on a claim for Part A or Part B benefits. It is the decision an appeal appeals — and an action that is not an initial determination carries no appeal rights at all.
Updated
An initial determination is the decision a Medicare contractor makes on a claim for benefits under Medicare Part A or Part B. 42 CFR 405.924(b) states that the contractor makes initial determinations regarding such claims, and gives a non-exhaustive list of what counts as one — whether the items or services furnished are covered, whether the deductible is met, how the coinsurance amount is computed, and others.
The term matters because of what follows from it rather than what it describes. The Medicare appeals ladder in 42 CFR part 405 subpart I runs from an initial determination upward, so an action that is one may be appealed and an action that is not one may not be. The regulation therefore comes in a matched pair: 405.924 lists actions that are initial determinations, and 405.926 lists actions that are not, opening with the statement that the actions it lists are not initial determinations and are not appealable under that subpart.
In practice
The practical question a billing office asks is not "was this an initial determination" but "do we have an appeal here", and they are the same question. A denial reached after the contractor adjudicated the claim is an initial determination and is appealable. Several refusals that look like denials on a remittance are not: 405.926 places determinations that a provider failed to file a claim timely at paragraph (n), and claim submissions that are incomplete, invalid, or do not meet the requirements for a Medicare claim and are returned or rejected at paragraph (s), outside the list.
405.924(b) draws the same line from the other side, stating that a finding that a request for payment or other submission does not meet the requirements for a Medicare claim, as defined at 42 CFR 424.32, is not considered an initial determination. Reading the action correctly is what routes the work: an appealable determination goes to redetermination, while a non-appealable action needs whatever different instrument the rules provide for it.
Reopening is not a substitute route. 42 CFR 405.980(a)(5) makes the decision on whether to reopen binding and not subject to appeal, and 405.926(l) puts a decision to reopen or not to reopen outside the initial-determination list as well — so the fallback carries no appeal of its own.
Commonly confused with
- Redetermination: A redetermination is the first level of appeal — a review of an initial determination by the contractor that made it. The initial determination is the decision under review; the redetermination is the review.
- Remittance advice: The remittance advice is the document that carries the decision to the provider, not the decision itself. 42 CFR 405.921(b) describes it as the notice of initial determination sent to providers and suppliers who accept assignment.
- Claim rejection: A rejection failed an edit before adjudication, so there is no determination in it to contest. 405.926(s) says so explicitly for submissions returned or rejected as incomplete or invalid.
Sources
- 42 CFR § 405.924(b) — actions that are initial determinations, and the requirements-for-a-claim exclusion (opens in a new tab)
- 42 CFR § 405.926 — actions that are not initial determinations and are not appealable under subpart I (opens in a new tab)
- 42 CFR § 405.980(a)(5) — a decision whether to reopen is binding and not subject to appeal (opens in a new tab)