If you disagree with Medicare's initial claim determination, you may request a redetermination.  A redetermination is the first level of appeal. Redeterminations must be requested within a specified time period. You may not request additional appeals unless you have first requested a redetermination.

• The request must be received within 120 days of the claim decision
• If a claim is submitted and denied multiple times, the time limit to request a redetermination starts with the initial determination
• Redetermination requests must be submitted in writing
• Redetermination request forms are available for download on our Web site in the 'Forms' section

Note: Claims rejected as unprocessable for billing or coding errors (remark code MA130) do not have appeal rights. Rejected claims must be corrected and resubmitted as new claims. Redeterminations or reopening requests for claims rejected as unprocessable will not be honored.

Assigned Claims

• The physician, the patient or the patient's representative may request a redetermination of an assigned claim
• Requests must be submitted in writing
• If a redetermination of an assigned claim is requested, the response will be sent to the requestor, unless we are advised to send the response to another party

Non-Assigned Claims

• Redetermination requests for non-assigned claims are handled differently. When the claim is non-assigned, a physician may request a redetermination only if the services were denied or reduced, based on medical necessity guidelines, and the physician is liable for the fee of the denied or reduced services.
• The physician may request a redetermination of a non-assigned claim if the beneficiary gives written authorization. This written authorization must be included with the redetermination request.
• If the beneficiary is deceased and the estate has no one available to appeal, or the estate chooses not to exercise its right to appeal (This should be documented on the appeal request)

Redetermination Decision
Once the redetermination request is completed, Palmetto GBA will provide a written response. The response will depend upon Palmetto GBA's decision:

• If the original decision on the claim is upheld, a detailed letter will be sent explaining why additional payment cannot be allowed
• 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 changed, but no further payment is due, a detailed letter will be sent explaining the reasons why no payment is forthcoming and a new remittance notice indicating the revised decision is issued
• If it is determined a portion of the claim can be allowed, a payment will be issued for the service(s) 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 service(s).

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