Requesting a Redetermination

A redetermination is an independent, re-examination of the claim file by the FI, A/B MAC and made by reviewers not involved in the initial claim decision. Contractors must handle and count incomplete redetermination requests as dismissals; make sure you include complete documentation.

 • The Beneficiary’s name

 • The Medicare Health Insurance Claim (HIC) number of the beneficiary 

 • The specific service(s) and/or item(s) for which the redetermination is being requested. 

 • The correct dates of service (include all from and through dates). 

 • The name and signature of the person filing the redetermination request. 

 • Include all pertinent medical documentation 

NOTE: Submitting a copy of the UB04 is not an acceptable appeal request. When submitting documentation, please include all documentation related to the redetermination including the Advanced Benefi ciary Notice (ABN).

You can use any form or letter as long you’ve included all of the required information. CMS has standardized forms (CMS-20027 and CMS-20031) you can use. To help ensure all requirements are met, Palmetto GBA has developed Appeal Forms for providers to use available on our website. 

Additional Documentation (ADR) in Direct Data Entry (DDE)  

To view any outstanding ADR requests for your facility, from the claim summary inquiry menu you will enter your provider number along with the status location of SB6001, currently this is the only location being utilized for ADRs:

• Type “S B6” in the S/LOC field. 

• Press [ENTER] and all claims in an S B6000 or S B6001 status/location will display. 

• Type an “S” in the SEL field of the desired claim and press [ENTER]. 

• The ADR letter immediately follows claim page 6 (MAP 1716). The ADR will consist of 2 pages.  

ADRs will stay in this status location only until the documentation is received. Do not use the [F9] function key with these claims. If you press [F9], the FISS will generate a new ADR.

Bill Types  

This three-digit alphanumeric code gives three specific pieces of information. The first digit identifies the type of facility. The second classifies the type of care. The third indicates the sequence of this bill in this particular episode of care. It is referred to as a frequency code.

The first digit identifies the type of facility.

1. Hospital

2. Skilled Nursing Facility 

3. Home Health

4. Religious Nonmedical (Hospital) 

5. Religious Nonmedical (Extended Care) discontinued 10/1/05 

6. Intermediate Care 

7. Clinic or Hospital based ESRD facility (requires Special second digit) 

8. Special facility or hospital (CAH) (ASC) surgery (requires special second digit) 

9. Reserved for National Assignment  

Second Digit (Except Clinics & Special Facilities) - Bill Classification 

1. Inpatient Part A 

2. Inpatient Part B (includes Part B plan of treatment) 

3. Outpatient (includes Part B plan of treatment) 

4. Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for “non-patients” and referenced diagnostic services. 

5. Intermediate Care - Level I 

6. Intermediate Care - Level II 

7. Sub-Acute Inpatient (Revenue Code 019X required) 17X, 27X discontinued 10/1/05 

8. Swing Beds 

9. Reserved for National Assignment

Second Digit (Clinics only) - Bill Classification 

1. Rural Health Center (RHC) 

2. Hospital based or Independent Renal Dialysis Center 

3. Other Rehabilitation Facility (ORF) 

4. Comprehensive Outpatient Rehabilitation Facility (CORF) 

5. Community Mental Health Center (CMHC)

6. Free Standing/Provider-based Federally Qualified Health Center (FQHC) 

7. Reserved for National Assignment 

8. Other 

Second Digit (Special Facilities only) - Bill Classification 

1. Hospice (non-hospital based) 

2. Hospice (hospital based)

4. Free Standing Birthing Center 

5. Critical Access Hospital (CAH) 

6-8. Reserve

9. Other