Palmetto GBA Medicare North Carolina Part A, South Carolina Part A and Regional Home Health and Hospice Intermediary (RHHI) Redetermination Request Form (Revised April 2009)
The Appeals Department has revised the Medicare North Carolina Part A, South Carolina Part A and RHHI Redetermination Form. Please note that only North Carolina Part A, South Carolina Part A and RHHI providers should use this form.
If you are a Jurisdiction 1 Part A or Part B provider, please do not use this form. Please use the Medicare J1 A/B MAC Part A Redetermination Form. This form is available on the Jurisdiction 1 Part A Web Page at www.PalmettoGBA.com/J1A or the Jurisdiction 1 Part B Web page at www.PalmettoGBA.com/J1B. Once you access the J1 Web pages, select Resources from the far left column and select Forms access the form.
When completing this form, please remember to submit each redetermination request separately. Please avoid stapling multiple redetermination requests together. This form is interactive. It can be completed online, printed and then mailed which means no more filling the form out by hand!
To access the North Carolina Part A, South Carolina Part A and RHHI Redetermination Form, select the PDF file below.