When to File an Appeal and When an Appeal Should Not be Filed

When to File Appeal

Services That Can Be Appealed

• You disagree with the amount paid 
• The service was denied as not reasonable and necessary
• The service was denied for failure to meet coverage criteria
• The service was denied as a contractual obligation, provider is liable, and you believe the provider is not responsible for the non-covered or denied services 
• The service was denied based on a review by the: 
  • Medicare Administrative Contractor (MAC)
  • Recovery Auditor Contractor (RAC) 
  • Comprehensive Error Rate Testing (CERT) contractor 
  • Supplemental Medical Review Contractor (SMRC)
  • Unified Program Integrity Contractor (UPIC)
  • Quality Improvement Organization (QIO)
  • Office of Inspector General (OIG)

When an Appeal Should Not be Filed

• Duplicate appeal/redetermination request. Palmetto GBA has 60 days; allow additional days for mail time for redetermination letters, to process an appeal/redetermination request. 
• When no initial determination has been made. Claims filed with no initial determination completed are not appealable; these claims and services are often considered rejected or unprocessable. Unprocessable claims must be corrected and resubmitted since they do not have appeal rights.
• In order to be eligible for an appeal, you must submit a Redetermination request to us within 120 days of the date you received this notice, unless you can provide documentation to show that you have good cause for filing late. See IOM, Publication 100-04, Chapter 29, Section 310.2.
• Claim has no appeal rights
• Return/Reject (R B9997) claims have no appeal rights, providers must correct claim error and submit new claim

Other Helpful Appeals Information

• Do not submit a new or corrected claim if you have a pending appeal/redetermination on file. Wait until you have received notice the appeal/redetermination is processed. 
• If you do not agree with the Redetermination decision, you may file a Second Level Reconsideration request to the Qualified Independent Contractor (QIC)

Submitting Redetermination Requests (Appeals)

The fastest most effective method to submit Redetermination Requests is through our Palmetto GBA eServices portal.

• Requests get to us right away and you control the data entered
• Supporting documentation may be submitted with your request or loaded later, if it is received before we have completed our decision
• Upon submission, you will receive a confirmation email from Palmetto GBA indicating that the appeal has been received 
• For more information please review the Appeals section of the eServices User Guide
• You may also complete the forms electronically from our website 
  • Type all information required on the form
  • Include your first and last name and contact information, in the event we have questions 
  • Attach supporting documentation 
  • Print and mail or fax to the address or fax number indicated on the form. The appeals form can be found on the Palmetto GBA website.