Appeal Rights: Know the Rules

Published 06/30/2020

You may appeal claims that are partially or fully denied as long as the claim has appeal rights. The appeal rights are outlined in your remittance notice. Appeals must be filed within 120 days of the date of the remittance notice.

Important Points to Remember

  • The 120-day clock begins with the initial determination. If you filed multiple claims and received multiple denials, the time begins with the remittance notice for the first claim. (Claims that are "returned as unprocessable" with remark code MA130 do not have appeal rights and are not subject to the 120-day timeframe.)
  • Please do not file duplicate appeal requests. Palmetto GBA processes most appeal requests within 60 days of receipt. Use the Palmetto GBA Redetermination Status tool to verify that your appeal request has been received.
  • If you have already submitted an appeal request, please do not resubmit the claim. Filing a new claim does not protect your appeal rights.

Claims that do not have appeal rights cannot be appealed. Examples include:

  • The claim was never filed with Palmetto GBA
  • The claim was "returned as unprocessable" with remark code MA130. Correct the billing errors (look for more specific remark codes on your remittance notice) and resubmit the claim.
  • The patient is not eligible for Medicare, or the patient’s records have not been updated through the Social Security Administration

We strongly encourage you to check the status of claims before submitting appeals through one of the following:

  • Use eServices
  • Call our Interactive Voice Response (IVR) line

You can also ensure that your claim has appeal rights by checking its status through the IVR unit or the eServices tool.

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