Provider Adjustments Denied for Medical Necessity or After an Appeal Has Been Submitted

Providers cannot adjust a claim or line item that has denied for medical necessity. These must be submitted as a redetermination. Please submit all appropriate medical documentation with the appeal.

If an appeal at any level has been submitted, the provider should not adjust a claim or line item regardless of the reason for the denial. If you have a need to adjust the claim that has been submitted for an appeal, the provider should send a request to withdraw the appeal. They may contact the Provider Contact Center or submit the request in writing. A written request to withdraw may be faxed to (803) 870–0138.

All needed adjustments should take place prior to the appeal process.

After a redetermination decision has been received from Palmetto GBA, the provider may proceed to the second level of the Appeals Process by requesting a reconsideration to C2C Innovative Solutions, Inc.: Qualified Independent Contractor (QIC) for Part A East Jurisdictions. Adjustments should not be done once the appeal process has begun.