Appeals

Published 06/16/2022

Healthcare Common Procedure Coding System (HCPCS) modifiers have very distinct definitions and uses within Medicare. There are times when a provider should use the GY HCPCS modifier to indicate that the "item or service statutorily excluded or does not meet the definition of any Medicare benefit." The services are specifically excluded based on a section of the Social Security Act. There are no Advance Beneficiary Notice (ABN) requirements for statutory exclusions.

When the GY HCPCS modifier is used, it will cause the claim to deny with the patient liable for the charges. These denials can be appealed by either the provider/supplier or the beneficiary. If Medicare pays the claim, the GY HCPCS modifier is irrelevant. The provider cannot collect amounts above the coinsurance and deductible or the limiting charge amount.

Last Reviewed: 6/16/2022

No, our telephone reopenings unit cannot accept a request to change the number of post-op days billed. Please submit your request in writing using a "Reopening: Simple Claim Correction" form or through eServices using a Simple Claim Correction eForm.

Note: If your claim was rejected with remittance advice remark message MA130, you must submit a new claim with the missing information. Reopening requests for rejected claims will be dismissed.

Not an eServices user yet? Sign up today to take advantage of online form submissions and the other time saving features including online eligibility and claim status, online remittances and eClaim submissions.

You can participate in eServices if you have a signed electronic data interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare. If you are already submitting claims electronically, you do not have to submit a new EDI Enrollment Agreement. See the eServices Portal section of our website for more information.

Last Reviewed: 6/16/2022

No, claims that have been rejected should be corrected and resubmitted as new claims. Rejected claims can be identified by Remittance Advice Remark Code (RARC) MA130 — Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

If you need assistance determining why your claim rejected, check the Palmetto GBA Denial Resolution Tool. The Denial Resolution Tool is alphabetized by type of service and reason for denial/rejection. After checking this tool, if you need assistance to understand why your claim was rejected as unprocessable, call the Provider Contact Center at 888–355–9165. Choose option 5 for Customer Service.

Last Reviewed: 6/16/2022

The Centers for Medicare & Medicaid Services (CMS) established a reopenings process which allows providers to request simple corrections to claims. The CMS reopenings process does not permit adding or deleting lines from a claim. However, if you have billed a claim or a claim line(s) in error, Palmetto GBA Railroad Medicare can adjust the claim to reflect the billing error and recoup any funds paid in error, if needed. When the claim is reprocessed, the adjusted claim line(s) will appear on your remittance advice with Claim Adjustment Reason Code (CARC) 112 — Service not furnished to the patient and/or not documented.

You can request a reopening by one of the following methods:

  • Call our Telephone Reopening line at 888–355–9165 Monday through Friday from 8:30 a.m. to 4:30 p.m. for all time zones, with the exception of Pacific Time, which receives service from 8 a.m. to 4 p.m. For reopenings, first press 4, and then to request a telephone reopening to correct minor errors or omission, press 0.
  • Submit a Reopening: Simple Claim Correction eForm through our eServices online portal
  • Submit a written reopening request by fax or mail

Fax your request to (803) 462–2218, or

Mail your request to:

Palmetto GBA Railroad Medicare
Attention: Appeals
P.O. Box 10066
Augusta, GA 30999 

A Reopening: Simple Claim Correction paper form is available on the Railroad Medicare Forms page. The form can be filled out online and then printed for submission.

Last Reviewed: 6/16/2022

You can use the Redetermination Status Tool on our website to check the status of an Appeal request using the Internal Control Number (ICN) of the claim in question.

When you are logged into eServices, you can use the Document Control Number (DCN) that is assigned to your Appeals request to look up form processing status and view your submitted forms on the Messages tab.

Last Reviewed: 6/16/2022

You can submit an appeal online through our eServices portal. The eServices portal is available to providers with an EDI Enrollment Agreement on file with Palmetto GBA Railroad Medicare. For more information about registering for the portal, see our eServices resources.

If you are already a registered eServices user, you can submit appeals through our Secure Forms section of the portal. If the secure forms function is available for you, you will see a Forms tab as part of the menu once you successfully log into your account. If you are a provider user who does not have permission to this tab, it will appear "grayed out." Please see your account administrator for access to the Forms fucntion.

To find an Appeals form, first select the Forms tab to access the Secure Forms screen. Then use the "Select a Topic" and "Select a Type" dropdown boxes to access the Appeals forms available to you.

Once you select the option to submit a Secure Form, a prepopulated form will appear with the information we have on file from your registration record. This will save you several steps. Then fill in all the information that is required for an appeal request (they are highlighted with red asterisks).

There is also an option to submit an appeal from the eServices Claim Status Information screen. First, select the Claims tab and use the Claim Status Inquiry function to locate your claim. On the List of Claim Status Information screen, click on the Submit an Appeal link. Answer the First Level Appeal Confirmation question that pops up and you will be directed to a pre-populated Redetermination: First Level Appeal form. Complete any remaining required fields such as the CPT® Codes(s), ICD-10 Code(s) and Reason for Appeal. 

Be sure to add attachments to support your appeal request. You may attach an unlimited number of PDF attachments to each form. Each attachment can be up to 40 MB in size. The total size of all attachments on each ADR form can be no more than 150 MB.

Your attachments can include, but are not limited to:

  • Supporting documentation
    • Orders
    • Invoices
    • Progress notes
    • Operative reports
    • Run/trip sheets for ambulance transports
  • Signed transfer of appeal rights form 
  • Appointment of representative form 

If you have any difficulties in uploading attachments or submitting the form, view our FAQ "How do I upload attachments to an appeal request" for more information.

Last Reviewed: 6/16/2022

You may add attachments up to 40 MB each to a form. While there is no longer a limit to the number of files that can be attached to this form, the combined size of all attachments cannot exceed 150 MB. All attachments must be PDF documents. Most scanners have the ability to save documents in the PDF format. If you receive an error when uploading the file, your form will refresh with the error listed at the top of the page, and the PDF will no longer be attached. Errors can occur if the PDF is corrupt or if it was not created using PDF software. For example, you cannot change a file extension to PDF. It will not be in the correct PDF format and you will be unable to upload it.

If your file is over 40 MB, you will want to break it down into smaller files in order to attach it to your form. You can do this through your PDF software or by changing your original files and creating the PDFs again.

Last Reviewed:6/16/2022

No, do not submit a new claim. If your claim was denied with remittance advice remark code RARC M127 because the information requested by Medical Review was not returned within 45 days of the ADR letter date, return your ADR response(s) as soon as possible within 120 days from the date of the receipt of the denial. Submit your documentation with a Medical Review ADR Response — Late Submission Form. If we receive your response more than 120 days from the receipt of the M127 denial, Medical Review will not review the documentation. The documentation will be handled as a redetermination by appeals. The receipt of the notice of the denial is presumed to be received five days from the date of the remittance advice.

Last Reviewed: 6/16/2022

If you need to correct a minor clerical error to a processed claim, please call our Reopenings telephone line at 888–355–9165. Choose option 4 for Telephone Reopenings. Representatives are available Monday through Friday from 8:30 a.m. to 4:30 p.m. for all time zones, with the exception of Pacific Time, which receives service from 8 a.m. to 4 p.m. Claims denied for timely filing and claims rejected with remittance message MA-130 cannot be reopened.

For more information about the types of Reopenings that can be processed by telephone, please see our article "Instead of a Written Redetermination: Consider Having Your Claim Reopened" located on our website. 

Last Reviewed: 6/16/2022