eServices Forms for Requesting a Reopening or Redetermination

Did you know many of the Reopening and Redetermination forms available on the Railroad Medicare Forms page are also available as secure eForms in the Palmetto GBA eServices portal? Using these eForms makes it easy for you to request a redetermination or reopening on a claim and track that request from the date of submission through completion. You can find instructions for submitting a secure form through eServices in Section 8.0 Secure Messaging and Forms in the Palmetto GBA eServices User Manual (PDF, 8.55 MB).

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. You can participate in eServices if you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare and have a claim in history.

If you choose to submit a paper form, it is important to regularly check the Palmetto GBA Railroad Medicare website for the most current form version. Paper forms can be completed online and printed 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 Completing the form online reduces the potential of using outdated forms and eliminates the need for our staff to manually enter the data on the form into our system.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 list of the available Reopening and Redetermination forms that are available as paper forms and eForms, along with an explanation of when the form would be used, is shown below:

Form Name 
Purpose of Form 
Reopening: Simple Claim Correction (AP-RRB-B-1020)
Use this form to correct a billing error on a claim that has been processed by Railroad Medicare. 
Reopening: Simple Claim Correction - Late Submission 
(AP-RRB-B-1021)
Use this form to correct a billing error on a claim that has been processed by Railroad Medicare it has been more than 1 year from the date of the Medicare remittance notice on that claim. 
Redetermination: 1st Level Appeal (AP-RRB-B-1000)
Use this form to request a redetermination (the first level of appeal) on a Railroad Medicare claim that does NOT involve an overpayment. 
Redetermination: 1st Level Appeal - Late Submission
(AP-RRB-B-1001)
Use this form to request a redetermination on a Railroad Medicare 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. 
Redetermination: Overpayment Appeal (AP-RRB-B-1010)
Use this form to request a redetermination on a Railroad Medicare overpayment.
 
(You should only use an overpayment redetermination form if you have received an overpayment notice from Medicare.)
Redetermination: Overpayment Appeal - Late Submission 
(AP-RRB-B-1011)
Use this form to request a redetermination on a Railroad Medicare overpayment if it has been more than 120 days from the date of the overpayment notice.

Contact Railroad Medicare

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Provider Contact Center: 888-355-9165

IVR: 877-288-7600

TTY: 877-715-6397

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