Jurisdiction J (JJ) and Jurisdiction M (JM) Part A Redetermination (First Level Appeals) Form

Published 10/18/2021

On October 14, 2021, Palmetto GBA identified incorrect fax numbers on the Jurisdiction J (JJ) and Jurisdiction M (JM) Part A Redetermination (first level appeals) forms. These forms have been updated to reflect the correct fax numbers:

  • JJ Part A: (803) 870–0138
  • JM Part A and HHH: (803) 699–2425

If you bookmarked or downloaded the forms between October 8 and October 14, 2021, please discard.

Palmetto GBA strongly encourages you to use our eServices portal to submit your first level redetermination requests. If you are unable to submit your Redetermination (first level appeals) request via our eServices portal, please use the updated form to submit your request for a Redetermination, and fax this form and all additional documentation to either, JJ Part A (PDF, 366 KB) (803) 870–0138 or JM Part A (PDF, 317 KB) and HHH (PDF, 265 KB) (803) 699–2425.