Palmetto GBA continues to receive Redetermination requests that are past the time limit. It is critical that you submit requests for redetermination within the time limits established by the Centers for Medicare & Medicaid Services. These time limits can only be extended in certain circumstances.
Redetermination requests must be submitted within 120 calendar days from the date on the initial determination notice. The initial determination notice is the:
Electronic Remittance Advice (ERA), or Standard Provider Remittance Notice (SPR) from the:
- First submission of that service
- Does not include any service rejected as a billing error (remark code MA130)
- If the date shown on your ERA or SPR is more than 120 days from the current calendar date, the timeframe for requesting a redetermination has ended
Example:
| Date of Initial Determination
(From the ERA or SPR)
| Current Calendar Date | Elapsed Days | Redetermination Rights | Date Redetermination must be received |
| 05/15/2007 |
10/15/2007 |
153 |
No |
09/17/2007 |
| 08/15/2007 |
10/15/2007 |
61 |
Yes |
12/18/2007 |
Note: Palmetto GBA allows a grace period of an additional five days beyond the time limit of 120 days from the date of the initial notice. This allows for a 5-day period for mail delivery. We may allow for additional time if you can provide documentation that mail delivery took longer than five days.
Extension of Time Limit for Filing a Request for Redeterminaiton
If an appeal request is filed late, Palmetto GBA may extend the time limit for filing a redetermination if you can demonstrate good cause. These extensions are not routinely granted, so it is important to provide supporting documentation if you are requesting an extension of this time limit.
References:
- CMS Publication 100-04, Chapter 29, § 60.11 (PDF, 586 KB)
- Use the Denial Finder tool to research denials. This tool provides resources that will help you submit the claim correctly and completely the first time. Access the tool right from the Ohio or West Virginia home page.
Remember: Claims rejected as unprocessable (billing errors, indicated with remark code MA130) have no appeal rights and cannot be submitted as Redetermination requests. The best way to handle these errors is to correct and resubmit the claim.