It's easy to submit a request for redetermination or reopening of a claim. Palmetto GBA has one form that can be used to submit either type of request.
The Redetermination/Reopening Request Form provides all of the information needed to quickly and accurately process your request once received in our office. You can download and fill out the form online in the Forms section from the the Palmetto GBA J1 Part B home page. Electronic Submission is not available at this time. Please print the completed form and mail it to:
J1 MAC - Palmetto GBA
P.O. Box 1252
Augusta, GA 30903-1252
Redetermination
A redetermination is the first of five appeal levels available for providers to contest initial claim determinations. There is no minimum controversy amount, but you must file a redetermination request within 120 days from the initial claim determination date in order to meet the timeliness requirement. Redetermination Requests that are not filed timely cannot be considered unless documentation is submitted to explain why the appeal was filed late.
Before you determine the need for a request, please check your submission information for accuracy, and then prepare your documentation.
If you are requesting a redetermination of an overpayment, please provide either the Financial Control Number (FCN) or the Accounts Receivable (AR) number found on the overpayment letter.
For all redetermination requests, please include the reason you disagree with the initial determination and attach any supporting documentation. If you have had a first level redetermination and want to appeal to the second level, please use the QIC Reconsideration form included with your appeal decision letter or the J1 Part B Reconsideration Form - QIC North found under the Forms section from the Palmetto GBA J1 Part B home page.
Reopening
In the case where a minor error or omission is involved, you can request Palmetto GBA to reopen the claim so such error or omission can be corrected:
- Mathematical or computational mistakes
- If you submitted the incorrect units (e.g., 1 instead of 2 in item 24G or its electronic equivalent), please be sure to adjust the charge accordingly
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer errors
- Duplicate denials, when you believe that the 'duplicate' denial is incorrect (e.g., ambulance trip denied as duplicate, but there were two identical trips on the same day)
- Incorrect data items, such as a modifier or date of service (month and day only)
- Adjustments to claims that were submitted in error that will result in an overpayment. Palmetto GBA will initiate the overpayment process when you notify us that this situation has occurred.
If the reopening request is the result of medical review decision (N102 on your Remittance Advice-RA), please attach a copy of the RA and any supporting documentation.
Note: Rejected claims (MA-130 on the RA) have no appeal rights and should not be sent for redetermination or reopening. Rejected claims should be corrected and resubmitted as new claims.
If you have any additional questions, please contact our toll-free J1 Part B Provider Contact Center at (866) 931-3901.