eServices Forms for Requesting a Reopening or Redetermination
Palmetto GBA has forms on the eServices portal to request redeterminations or reopenings on your Medicare Part B claims. These forms make it easier for providers to request a redetermination or reopening on a Part B claim and track that request from the date of submission through completion.
Increased use of eServices forms by providers allows Palmetto GBA to automate more of the appeal and reopening processes. This results in quicker and more transparent processing of your request. If you have not already signed up for Palmetto GBA's eServices, please look over the information on our website and consider joining the providers who are already benefiting from this innovative option.
It is important to regularly check the Palmetto GBA website for the most current version. The form can be completed online and printed and signed for submission. Completing the form online reduces the potential of using outdated forms and eliminates the need for our staff to manually enter the data on the form into our system.
A total list of the available forms, along with an explanation of when the form would be used, is shown below:
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Form Name
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Purpose of Form
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Reopening: Simple Claim Correction (AP-JJ-B-1020)
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Use this form to correct a billing error on a claim that has been processed by Medicare Part B.
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Reopening: Simple Claim Correction — Late Submission (AP-JJ-B-1021)
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Use this form to correct a billing error on a claim that has been processed by Medicare Part B if it has been more than 1 year from the date of the Medicare remittance notice on that claim.
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Redetermination: First Level Appeal (AP-JJ-B-1000)
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Use this form to request a redetermination (the first level of appeal) on a Medicare Part B claim that does not involve an overpayment.
(Previously, this was the only redetermination form available in eServices.)
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Redetermination: First Level Appeal — Late Submission (AP-JJ-B-1001)
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Use this form to request a redetermination on a Medicare Part B claim that does not involve an overpayment if it has been more than 120 days from the date of the remittance notice for the claim.
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Redetermination: Overpayment Appeal (AP-JJ-B-1010)
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Use this form to request a redetermination on a Medicare Part B overpayment that is not related to a RAC, CERT or ZPIC case.
(You should only use an overpayment redetermination form if you have received an overpayment notice from Medicare.) |
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Redetermination: Overpayment Appeal — Late Submission (AP-JJ-B-1011)
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Use this form to request a redetermination on a Medicare Part B overpayment that is not related to a RAC, CERT or ZPIC case if it has been more than 120 days from the date of the overpayment notice.
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Redetermination: Recovery Audit Contractor (RAC) (AP-JJ-B-1030)
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Use this form to request a redetermination on a Medicare Part B overpayment on a claim that was reviewed by the Recovery Audit Contractor.
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Redetermination: Recovery Audit Contractor (RAC) — Late Submission (AP-JJ-B-1031)
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Use this form to request a redetermination on a Medicare Part B overpayment on a claim that was reviewed by the Recovery Audit Contractor IF it is more than 120 days from the date of the overpayment notice.
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Redetermination: Comprehensive Error Rate Testing — CERT (AP-JJ-B-1040)
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Use this form to request a redetermination on a Medicare Part B overpayment on a claim that was reviewed by the CERT Contractor.
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Redetermination: Comprehensive Error Rate Testing — CERT Late Submission (AP-JJ-B-1041)
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Use this form to request a redetermination on a Medicare Part B overpayment on a claim that was reviewed by the CERT Contractor IF it is more than 120 days from the date of the overpayment notice.
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Redetermination: Zone Program Integrity Contractor — ZPIC (AP-JJ-B-1050)
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Use this form to request a redetermination on a Medicare Part B overpayment that was initiated by the ZPIC.
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Redetermination: Zone Program Integrity Contractor — ZPIC Late Submission (AP-JJ-B-1051)
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Use this form to request a redetermination on a Medicare Part B overpayment that was initiated by the ZPIC IF it is more than 120 days from the date of the overpayment notice.
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