LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-05 Providers Mis-Mailing Redetermination Requests After ADR Denied

Palmetto GBA Home / Jurisdiction 11 Part B
Jurisdiction 11 Part B

Alert: Redetermination Requests Are Inappropriately Being Sent to the Medical Review Department and Cannot be Forwarded to the Appeals Department for Processing
  • Palmetto GBA has noticed a trend in providers sending in redetermination requests to the medical review department after their additional development request (ADR) results in a denied claim. Providers should note that the medical review department does not process re-determinations and cannot forward the documentation on to the appeals department without the redetermination request form.
  • If a provider receives an ADR, submits documentation and then has their claim denied by the medical review department, the next step would be to submit a redetermination request. Providers can do this by accessing the appropriate redetermination request form from the Palmetto GBA website under the ‘Forms’ section and submitting the form, along with the documentation, to the address listed on the form. This assures that the documentation is received and processed in the allowed amount of time. Misrouted documentation that does not include the redetermination request form cannot be processed and could result in a provider missing timeliness guidelines for filing a Medicare redetermination request.
  • Note: A provider has 120 days from the date the claim is denied on the Medicare remittance advice to request a redetermination.

last updated on 05/06/2013