C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

42 C.F.R. § 405.948

Conduct of a redetermination

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A redetermination consists of an independent review of an initial determination. In conducting a redetermination, the contractor reviews the evidence and findings upon which the initial determination was based, and any additional evidence the parties submit or the contractor obtains on its own. An individual who was not involved in making the initial determination must make a redetermination. The contractor may raise and develop new issues that are relevant to the claims in the particular case.

Notes of Decisions
Cited in 11 cases (8 in the last 5 years), 2010–2025 · leading case: Sahara Health Care, Inc. v. Alex Azar, II, Secreta, 975 F.3d 523 (5th Cir. 2020).
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Sahara Health Care, Inc. v. Alex Azar, II, Secreta, 975 F.3d 523 (5th Cir. 2020). “§ 1395ff(a)(3); 42 C.F.R. § 405.948 . Sec- ond, a provider can seek “reconsideration” from a qualified independent contractor.”
Almy v. Sebelius, 749 F. Supp. 2d 315 (D. Maryland 2010). · cites it 2× “42 C.F.R. § 405.948 . A party receiving a “redetermination” may seek further review by applying for a “reconsideration” by a qualified independent contractor (“QIC”).”
Med-Cert Home Care v. Becerra, 19 F.4th 828 (5th Cir. 2021). “§ 1395ff(a)(3); 42 C.F.R. § 405.948 . Step two involves “reconsideration” by a qualified independent contractor.”
North Carolina Ins. Guar. Ass'n v. Xavier Becerra, 55 F.4th 428 (4th Cir. 2022). “” 42 C.F.R. § 405.948 . Second, if the insurer is dissatisfied with the result of the 3 According to CMS’s website, a Medicare Administrative Contractor (“MAC”) is “a private health care insurer” who is “responsible for administering Medicare Part A and Part B claims.”
Art of Healing Med., P.C. v. Burwell, 91 F. Supp. 3d 400 (E.D.N.Y 2015). “Redetermination requests may be dismissed on various procedural grounds, including lack of a valid request, failure to file within the proper filing time, and lack of an initial determination on the claim. Id. at § 405.”
Gen. Med., P.C. v. U.S. Dep't of Health & Human Servs., Sec'y of (E.D. Mich. 2023). “42 C.F.R. § 405.948 . At this first stage of an administrative appeal, the MAC conducts an “independent review” of the relevant evidence and determines whether the initial determination of overpayment was erroneous.”
I & R Med., P.C. v. Hargan (E.D.N.Y 2021). “” 42 C.F.R. § 405.948 . Following redetermination, a dissatisfied party may then request reconsideration by a QIC within 180 days, regardless of the amount in controversy.”
Integrity Soc. Work Servs., LCSW, LLC v. AZAR (E.D.N.Y 2021). “” 42 C.F.R. § 405.948 . Recoupment pauses “upon receipt of a timely and valid request for a redetermination of an overpayment.”
Angels of Care Home Health Inc v. Azar, II (N.D. Tex. 2021). “§ 1395ff(a)(3); 42 C.F.R. § 405.948 . 13 42 U.S.C. § 1395ff(b)-(c), (g); 42 C.”
Med-Cert Home Care, LLC v. Azar, II (N.D. Tex. 2023). “§ 1395ff(a)(3); 42 C.F.R. § 405.948 . Second, a provider can seek “reconsideration” from a qualified independent contractor [(“QIC”)].”
Compass Lab'y Servs., LLC v. Becerra (W.D. Tenn. 2025). “” See 42 C.F.R. § 405.948 . If the provider is still dissatisfied, it can seek the second step, which is “reconsideration” from a Qualified Independent Contractor (“QIC”).”
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