Prevent Duplicate Appeal Requests
An analysis of appeal receipts has shown a significant increase in the number of duplicate appeal requests being received for the same patient and the same service. This increases the number of appeals that must be worked, which in turn increases the time it takes Palmetto GBA to complete the appeal.
As your Specialty Medicare Administrative Contractor (RRB SMAC), 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 Railroad Medicare website to check the status of your appeal. The status tool is located under ‘Self Service 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:
- One request is submitted hard copy and another request is subsequently faxed
- It is not necessary to send separate requests by mail and by fax
- One request is submitted hardcopy and sent via certified mail. The same or next day, the exact same request is submitted hard copy in the same manner. Please only send one request.
- One request is faxed and on the same day (or within the next couple of days) a second request is faxed
- If you think the original fax was not received, please contact the Provider Contact Center or check the redetermination status tool to confirm receipt before submitting a second request. It may take a few business days for your request to show up on our system. Please allow some time and check the status of your initial request to verify whether or not it was received before submitting a second request.
- Be sure to include all documentation with your initial faxed request, to prevent the need for submitting a second request. If you think the original fax did not contain all required documentation, please contact the Provider Contact Center. The Provider Contact Center will help you determine if the missing information is needed. If the missing information is needed, the Provider Contact Center will help get the missing information to the Appeals area.
- Prior to faxing, be sure the request form is completed correctly and is signed by the appellant to prevent the need for a second request
- Verify the fax number prior to faxing the request to us. Sending your request to two different fax numbers within Palmetto GBA can result in duplicate requests if the original fax is forwarded to the Appeals department for processing. If you think you sent your request to an incorrect fax number, please contact the Provider Contact Center, or check the redetermination status tool before sending a second request.
- One request is submitted with a spreadsheet listing each patient and date of service (DOS) being appealed (or with a copy of a Medicare Remittance Notice (MRN) with multiple claims highlighted). In addition, a separate appeal request form is submitted for each patient listed on the spreadsheet or MRN.
- 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 it 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:
- Submit all documentation to support your appeal with the initial redetermination request
- Hold off submitting your redetermination request, if at all possible to allow submission of all documentation at one time. This will assure that everything submitted for that case is included in your review.
- 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.