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Railroad Medicare
Guide to Medicare Forms

Railroad Medicare offers forms for many transactions, such as requesting an appeal or a Reopening, submitting financial requests, reporting overpayments, submitting a written inquiry, etc.

The following table explains which form you should for each type of request.

 

 Form Purpose
CMS Advance Beneficiary Notice of Noncoverage (ABN)

Notify a Medicare patient that a service being rendered may not be paid by Medicare.

More Information:

Overpayment Refund Form

Notify Palmetto GBA when you identify an overpayment from Medicare.

Please visit our Railroad Medicare Forms to use the form appropriate for your request. 

Extended Repayment Plan (ERP) Form

Request an ERP when an overpayment is assessed and you cannot repay the amount within 30 days of receipt of the first demand letter.

Please visit our
Railroad Medicare Forms to use the form appropriate for your request.  
 

Reopening Requests

Minor clerical errors can be conducted through the Reopenings process. A Reopening is not an Appeal and does not remove Appeal rights from claims that are reopened.

More Information:
Many Reopenings can be handled through our Reopenings telephone line at (866) 324-3073; however some can only be conducted in writing.

These include:

  • Situations involving 'Limitation of Liability' (i.e., issues involving Advance Beneficiary Notices)
  • Claims denied or reduced due to medical necessity
  • Claims that require operative reports and/or clinical summaries (e.g., surgery claims submitted with CPT modifier 22)
  • Claims requiring the input of our medical staff or other entities outside of the reopening department and big box cases
  • Requests to change liability from the provider to the beneficiary
  • Requests to add items or services not originally submitted to Medicare

Please visit our Railroad Medicare Forms to select the form appropriate for your request.

You can fax your request to (706) 855-3148 or mail to the address listed on the form.

Redetermination Requests

(No Overpayment)

Parties dissatisfied with an initial claim determination have the right to appeal the determination. 

More Information:

  • Redetermination requests must be submitted in writing within 120 days of the date of the initial claim determination
  • Please note:  Claims that are 'returned as unprocessable' (remark code MA130) do not have any appeal rights and should not be sent for redetermination. These claims must be corrected and resubmitted as new claims
  • Please visit our Railroad Medicare Forms to use the form appropriate for your request. Be sure to include supporting documentation

You can fax your request to (706) 855-3148 or mail to the address listed on the form.

Overpayment Appeal Requests 

If you are appealing a claim involving a demanded overpayment, use our Overpayment Appeal Request Form in our Railroad Medicare Forms section.

More Information:

  • Overpayment Appeal requests must be submitted in writing within 120 days of the date of the initial claim determination
  • Include a copy of your overpayment letter demand letter and  documentation to support your review request

You can fax your request to (706) 855-3148 or mail to the address listed on the form.

Reconsideration Request Form

Request the second level of appeal.

More Information:

  • A reconsideration is 'an appeal of an appeal.' This form may be used only after a redetermination (first level of appeal) has been completed and you wish to appeal the contractor’s redetermination decision to the next level. The reconsideration is the second level of appeal.
  • Do not submit these forms to Palmetto GBA.
  • Use this Reconsiderations link to access the form, other instructions and mailing address: Reconsiderations: The Second Level of Appeals   
Written Inquiry Form

Submit a question to Palmetto GBA.

More Information:

  • The form makes it easy for you to submit all required authentication information (NPI, PTAN, and TIN) and a clear description of your question
  • It also includes other resources that may help you obtain a quicker response

Please visit our Railroad Medicare Forms to select the form appropriate for your request.

MSP Explanation Form Provide supporting documentation for paper MSP claims. This form is particularly useful for situations in which the primary insurers' explanation of benefits (EOB) is very general regarding the reason the service was denied or only partially paid.

Please visit our Railroad Medicare Forms to select the form appropriate for your request.

 


 

last updated on 08/20/2012
ver 1.0.51