- Filing an Appeal
- Frequently Asked Questions
- Helpful Websites
- Overpayment Appeals
- Which Form Do I Use?
How to Submit Part B Redetermination Requests
If you are dissatisfied with how your Medicare Part B claims processed, you can request a first-level appeal (redetermination). Palmetto GBA is responsible for completing first-level appeals for any Part B claims that were processed by the JM Medicare Administrative Contractor (MAC).
When you submit a redetermination request, you should include any medical records and documentation that the reviewer will need to determine if the service was medically necessary and met all coverage and billing regulations. If records are not sent, Palmetto GBA will make an appeal decision based on whatever information is available in our system. It is not necessary to provide copies of National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs).
Note: Please make sure that any medical records are signed by the rendering or ordering physician or nonphysician practitioner, as required.
How to Submit an Appeal on a Part B Claim
Redetermination requests can be submitted to Palmetto GBA through the eServices internet portal, by mail or by fax. Information on each of those options is provided below:
1. Internet Portal — The simplest and most efficient way to submit a redetermination is through Palmetto GBA’s eServices portal. It is fast, easy, and allows you to submit all supporting documentation. eService submissions reach us immediately. The receipt date for requests received after 4:30 p.m. ET will be considered as the next business day.
The eServices option gives you greater control over documents by allowing you to key information into the form and attach the appropriate documentation. This helps prevent keying errors and ensures your redetermination or reopenings are immediately routed to the correct department. You will then receive a message confirming receipt.
Palmetto GBA also offer an eDelivery option for receiving your redetermination decision letters electronically. You can get your Medicare redetermination notices (MRNs) the same day that they are issued, delivered directly to your computer. You can even choose to get an email to let you know that the letter is waiting for you.
For more information on how to sign up for eServices and submit appeals using this tool refer to the Palmetto GBA eServices User Guide (PDF, 8.5 MB).
2. Mailing Your Redetermination Request — You can send your redetermination request to us via the U.S. Postal Service or other delivery service. Palmetto GBA provides a redetermination form on the website that is available in the Forms option. Once the required fields on the form have been completed, you can print the form and mail it to the address shown below:
Palmetto GBA JM Part B Appeals – AG-655
PO Box 100190
Columbia, SC 29202–3190
Please make sure that any medical records are signed by the rendering or ordering physician or nonphysician practitioner, as required.
3. Faxing Your Redetermination Request — You can fax the redetermination request to us along with the documentation that is needed to determine if the services are medically necessary and covered under Medicare’s guidelines.
- No special preparation is necessary for redetermination requests submitted via fax. The redetermination request form can serve as the fax cover sheet.
- Please limit the number of pages per redetermination request to no more than 150
- The receipt date for faxed requests received after 4:30 p.m. ET will be considered as the next business day
Palmetto GBA provides a redetermination request form on its website that is available in the Forms option. Once the required fields on the form have been completed, you can print the form and attach the necessary documentation.
The JM Part B Appeals Redetermination Fax Number is (803) 699–2427.
The redetermination fax number may only be used for redetermination requests. Do not fax any other requests or information to this number.
Other Tips for all Redetermination Requests
- Claims that were rejected (MA-130 on your remittance notice) cannot be appealed. You must correct the error and submit a new claim to be processed.
- All redetermination requests must be submitted within 120 days of the date of the initial determination to be considered timely
- Redetermination requests submitted must contain the following information to be considered valid:
- Beneficiary name;
- Medicare Beneficiary Identifier (MBI/HIC);
- The specific service(s) and/or item(s) for which the redetermination is being requested;
- The specific date(s) of service; and
- The name of the party or the representative of the party requesting the appeal
- Redetermination requests submitted without all of the above information will be dismissed as incomplete
- If the redetermination involves an overpayment situation, you should attach a copy of the overpayment demand letter and any spreadsheet or claims listing with your appeal request. Please let us know if the overpayment is in relation to a CERT, RAC, UPIC or other specific type of overpayment.
- Regardless of how you submit your request, redeterminations will be completed within 60 days from the date that we receive your request