Appeals Quick Tips

If you are dissatisfied with an initial claim determination, you have the right to request an appeal. There are several appeal levels, and each level must be processed before proceeding to the next level. There are a total of five levels.

• Level 1: Redetermination
• Level 2: Reconsideration
• Level 3: Administrative Law Judge Hearing
• Level 4: Appeals Council Review
• Level 5: Judicial Review

 A Medicare Administrative Contractor (MAC) has 60 days of receipt, to decide on a redetermination. If the appeal decision is partially of fully favorable to pay, please allow additional time for the claim to be effectuated.

As a reminder, if a party requests QIC review of a contractor’s dismissal of a request for redetermination, the time limit for filing a request for reconsideration is 180 days from the date of receipt of the contractor’s dismissal notice. Please reference CMS IOM 100-04 Chapter 29 Section 220 Chart 1 — The Medicare Fee-for-Service Appeals Process (PDF).

Interactive Voice Response System (IVR) and Appeal Letters
If a provider has received a Fully Favorable Appeal, a notification letter would not be mailed. Partially Favorable and Unfavorable Appeals will have a letter of notification issued to the provider. Part A/HHH appeal letter copies can be obtained from the Interactive Voice Mail Response (IVR) System unless it is a Master Case. Those letters will not be on the IVR.

eServices
JJ Part A, JM Part A and HHH users can access appeals data from the Claims Lookup feature located under the Claims tab. 

• If no appeals are found, “Submit an Appeal” button will be displayed. Users will be redirected to the Redetermination form after confirming whether the appeal is late (over 120 days).
• If a Level 1 appeal is found, the status of the appeal will be provided. Multiple links are available for Level 1 appeals. The links are made available based on the status of the appeal. “View Decision Letter link” will allow users to download and view the decision letter of the appeal. 

Resource: eServices Appeals Feature.

Submitting Appeals via eServices Portal
By using eServices, providers can electronically submit an appeal request and PDF attachments online. Once submitted, you will receive a confirmation from Palmetto GBA indicating that the appeal has been received. For more information, please review the "Appeals" section in the eServices User Manual (PDF).

You may also download the forms from the Palmetto GBA website and submit them via U.S. mail or fax.

• Please enter the data in the PDF form, include your first and last name. You can now print the form.
• Once the form(s) are completed, attach the complete medical record (if applicable) and mail to the address indicated on the form. The appeals form can be downloaded from our website at: Jurisdiction J Part A (PDF), Jurisdiction M Part A (PDF), HHH (PDF).
• Or, you have the option to submit requests for a redetermination and the medical record via fax at (803) 699–2425
• First level of appeal: redetermination. Timeframe: 120 days from the date of the initial determination. Services that are "returned to provider" with remark code MA130 must be corrected and resubmitted, and not appealed.
• Reconsideration requests can now be filed via the eServices portal or they can be mailed directly to the QIC. The address for the QIC is included in the redetermination letter. You should include a copy of the redetermination decision letter with your request.
   

Appeals Status Tool 

• JJ Part A
• JM Part A
• HHH

Located on the Jurisdiction Page of Part A/HHH landing pages under the Tools heading. This tool allows a provider to view the Part A Redetermination Status that has been received by Palmetto GBA. This tool will provide the most current status of your Part A/HHH appeals.

Appeals Calculator Self Service Tool

• JJ Part A
• JM Part A
• HHH

Providers may appeal claims that are partially or fully denied, as long as the claim has appeal rights. Different levels of appeals have different timelines in which the appeal rights are valid. A provider will simply select their appeal level, enter the date of the initial determination notice and the tool will calculate the receive by date of the contested appeal.