Shorten Appeals Decision Times by Avoiding Duplicate Appeals Requests


To meet standards set by the Centers for Medicare & Medicaid Services (CMS), Medicare Administrative Contractors (MACs) must complete first-level appeals (redeterminations) within 60 days from the date of receipt. Palmetto GBA is dedicated to meeting or exceeding this government standard.
 
One of the challenges we face in completing appeals timely is identifying duplicate appeal requests and matching those requests together so that our efforts are not duplicated and only one appeal decision is generated. It would help us to complete appeals more efficiently (and get decisions back to you faster) if we received fewer duplicate requests.

How Are Duplicate Appeals Generated?
The following situations provide examples of when duplicate appeal requests are created:

  • Appeals are requested using different methods:
    • Example 1 — One appeal request is submitted via the eServices portal and another request is faxed or mailed
    • Example 2 — An appeal request is sent to us via U.S. Postal Service and another request is faxed
    • Example 3 — An appeal request is submitted via certified mail. The same request is submitted via regular U.S. Postal Service or by fax

If you have submitted an appeal request by one method (online, fax or mailed), there is no reason to submit another request using a different method. If you are not sure that the first request was received, wait a few days, then check the status of the request using the Redetermination Status Tool on the Palmetto GBA website.

  • Multiple faxes are sent:
    • Example — An appeal request is sent via fax machine. The person sending the faxes is not sure that the entire request was transmitted, so she/he sends a second, third or fourth fax to make sure everything was received.

There are instances where we have received 20 or more copies of the same appeal request via fax because the provider was not sure that the transmittal was sent. Matching several requests into one appeal case file is time-consuming. Please make sure that your fax machine is working correctly before trying to transmit an appeal request. If you are not sure the fax transmittal was received, please wait a couple of days and check the status of the request before sending another transmittal.

Or, if your fax machine is equipped to generate a fax confirmation page, please enable that function.

Rather than using a fax machine, you can submit your appeal requests electronically via the internet if you sign up for eServices. Using eServices, you will receive a notice that the appeal was received, so there is no question as to whether the request was transmitted. You can attach records to your request, so you know that all of the necessary information is available for review with your appeal.

  • Follow-up requests are sent before waiting for 60 days:

Automatic follow-up appeals — Some providers automatically send duplicate requests after a set time frame. Medicare Administrative Contractors are allowed 60 days to complete first-level appeals. If providers are set up to automatically send a second request after only 30 or 40 days, the second request will have to be manually matched in our system to the original request. This slows down the appeals process.

You should wait at least 60 days for an appeal decision before sending a follow-up request. 

  • The first request is incomplete, so a second request is sent

Please take the necessary time to make sure the appeal request form is completed correctly and that any medical records are attached before sending your appeal request. If you think the original request did not contain all required documentation, please contact the Provider Contact Center (PCC). The PCC representative can help you determine if the missing information is needed. If so, the PCC representative can help you get the missing information to the Appeals area.

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 submit appeal requests using eServices, the system will let you know if any required information is missing.

  • One request is submitted that includes multiple claims, then separate appeal requests are sent for each individual claim:

If you are appealing several claims for the same beneficiary or for the same issue, you can combine those requests and submit one appeal. You would then attach information for each of the appealed claims to the one request. We have seen instances where a provider would submit one appeal for the group of claims, then submit separate appeal request on each of those claims. 

For cases involving multiple claims, spreadsheets can be used to provide information on each claim. The spreadsheet should contain the information needed to identify each patient and make clear what you are asking us to do. Please don’t try to fit too much information on the spreadsheet. Using a small font size will make it difficult (or impossible) for our reviewers to read the necessary information. If multiple issues are being appealed, note the specific issue next to each beneficiary on the spreadsheet. 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 up when scanned. Indicate with a check mark (or some other obvious indicator) the claims to be reviewed.

Separate appeal requests are submitted for different charges that are included on the same claim:
  • If possible, you should submit one appeal request for all the charges you are appealing on the same claim. Sending separate requests for different charges on the same claim makes it difficult to identify duplicate appeal requests. One of the requests could be flagged as an exact duplicate, which could result on one of the charges being missed when the appeal is completed.
  • Appeal requests are sent to different fax numbers

You should always verify the fax number prior to faxing a request to us. Sending medical information to an incorrect fax number violates privacy laws. Sending your request to two different fax numbers within Palmetto GBA will result in duplicate requests if both requests are forwarded to the appeals department for processing. If you think you sent your request to an incorrect fax number, please contact the PCC.

Submit Your Appeal Requests 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, 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.




Last Updated: 07/02/2020