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Printed Date: 9/22/2015
As a Medicare Administrative Contractor (MAC), Palmetto GBA has 60 days to complete a redetermination decision. If you are not sure if your request has been received, please use the redetermination status tool on the Palmetto GBA website to check the status of your appeal. The status tool is located under Forms/Tools and will let you know if your request is being processed.
The following bullets include examples of situations that result in duplicate appeal requests:
Please submit only one appeal request form with the spreadsheets or MRNs and not individual claim forms. If multiple issues are included, note the specific issue next to each beneficiary on the spreadsheet. The spreadsheet should contain all of the information needed to identify each patient and make clear what you are asking us to do. At a minimum, the spreadsheet should include the patients’ Medicare numbers and names, the dates of service and the procedure codes being appealed. If MRNs are submitted with the appeal, be sure to indicate which patients you are appealing. Remember, highlighting does not show when scanned. Indicate with a check mark (or some other obvious indicator) the claims to be reviewed. If they are all being appealed for the same reason, you do not need to send CMS 1500 claim forms* as long as the required information is on the appeal request form or attached spreadsheet.
*Note: If you send the CMS 1500 claim forms, place them after the spreadsheets or MRNs being submitted
An appeal request is submitted for each service on the claim.
Please indicate on the appeal request form all items you are appealing for the claim. Do not send a separate request for each service.
In some cases, redetermination requests are submitted, and within one to five days after the first submission a second request is submitted with one or two additional pages that were not included with the original submission. To ensure that the additional information is matched with your initial request, please consider the following:
Instances where additional information is submitted later should be rare. Additional documentation will only be considered in cases where Palmetto GBA has not yet completed the redetermination decision. If the redetermination decision has been completed, a Reconsideration will have to be filed at the Qualified Independent Contractor (QIC). If you have to submit documentation after your appeal request has been sent, do so quickly and be sure to mark your second submission as follows: "Additional Documentation Submission for Redetermination request submitted on (DATE)."
If the only item that you are missing on your request is a copy of the remittance notice, please do not submit this separately. As long as your request included enough information to identify the claim and service being appealed, we do not need a copy of the remittance notice to complete the appeal.
To ensure confidence your appeal has been received, submit via eServices. Submitting an appeal request is easy using the eServices portal on the Palmetto GBA website. Once you have submitted the form, you will receive an email confirmation that the form was received by Palmetto GBA. Once the form has been accepted into our processing system, an additional message will be generated with the Document Control Number (DCN). Using the eServices method to submit your appeal requests provides a layer of confidence your appeal has been received.
There is no cost to the provider for registering and using eServices.
Palmetto GBA’s eServices is an Internet-based, provider self-service secure application. Palmetto GBA’s goal is to give the provider secure and fast access to their Medicare information seamlessly via our website through the eServices application.
You can participate in eServices if you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA and have payment amounts on file. To find instructions on how to get one, go to the EDI section of PalmettoGBA.com.
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Last Updated: 07/05/2019