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 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 and that documentation meets the requirement to show good cause for late filing.
Before you determine the need to request a redetermination, please check your submission information for accuracy, and then prepare your documentation. As you select the supporting documentation for your request, keep the following information in mind:
- All policies and procedures applicable to the claim will be considered
- Please ensure that you attach documentation to support the complete questioned service and all services on your claim. For example, a global procedure request should include documentation to support all services provided during the global period in addition to the other services listed on the claim. If you only submit the documentation for one service, you might not obtain your desired results.
Note: Claims rejected as unprocessable (billing errors, indicated with remark code MA130) have no appeal rights and should not be submitted as redetermination requests. The only way these can be considered is for the claim to be corrected and resubmitted.
Appeals for Multiple Claims Involving the Same Issue
If multiple claims involve the same issue, it is not necessary to submit each appeal separately. A single appeal can be filed for multiple claims. If multiple claims involve the same issue, one appeal request can be submitted with all claims included. All appeal requests must be submitted in writing. Each claim in a multiple request must be clearly identified in some manner to allow identification of:
- The beneficiary
- The Medicare Health Insurance Claim (HIC) number
- The specific service or item for which the redetermination is being requested (copies of the Remittance Advice or a spreadsheet are acceptable)
- The specific dates of service
To ensure you receive a successful decision on single or multiple appeal requests, review the six key items listed below:
- Requests submitted without all appropriate signed documentation might result in an unfavorable decision for the provider
- All applicable claim lines and claim details are reviewed for medical necessity, correct coding and supportive documentation
- Additional claims pertaining to the questioned service are subject to review and possible adjustment
- The number of claims you appeal can by reduced by ensuring that you submit all appropriate documentation, including applicable modifiers and ICD-9 codes, with the initial claim. Be sure that your medical record documentation supports the information you are submitting.
- All requests must contain the name and signature of the person requesting the appeal
- If a claim is submitted and denied multiple times, the time limit to request a redetermination starts with the first claim determination
Once the redetermination request is completed, Palmetto GBA will provide a written response. The response will depend upon Palmetto GBA's decision:
- If it is determined the original decision on the claim can be changed and payment is due, a new remittance notice and a payment will be issued
- If the original decision on the claim is upheld, a detailed letter will be sent explaining why additional payment cannot be allowed
- If the original decision on the claim is changed, but no further payment is due, a detailed letter will be sent explaining the reasons why no payment is forthcoming
- If it is determined a portion of the claim can be allowed, a payment will be issued for the services allowed, with a corrected remittance notice. A separate detailed letter will be sent explaining the adjustment and explaining why additional payment cannot be allowed on the other services.
Use the 'Redetermination: 1st Level Appeal Form' in the Forms section of the J1 Part A or Part B Web site. Only one form is needed for a multiple appeals request. For a multiple appeals request, the form can be filled out with the information for the first claim in question. In the Reason for Request box, identify the multiple requests along with your reason for the appeal.