Recovery Audit Contractor
If records were submitted to the RAC, providers are not required to submit medical records to the MAC, but it is encouraged. Providers have the option to send the records directly to the Palmetto GBA Appeals Department.
Palmetto GBA
HHH Appeals
Mail Code: AG-630
P.O. Box 100238
Columbia, SC 29202-3238
Fax: (803) 699-2425
Fed Ex/UPS/Certified Mail Address
Palmetto GBA
HHH Appeals
Mail Code: AG-630
Building One
2300 Springdale Drive
Camden, SC 29020
Last Reviewed: 09/28/2023
After the QIO decision, if monies are still due, the provider should receive a demand letter from Palmetto GBA.
Last Reviewed: 09/28/2023
It is important to note that providers are responsible for submitting records to the RAC in response to a complex review (a review that involves a full review of all medical records and billing information related to the claim involved) within the timeframe expressed by the demand letter. If records have not been provided to the RAC, as is case for an automated review (based upon data analysis), then it will be necessary for the provider to submit records to Palmetto GBA if an appeal is filed. It is vital that the provider submit records when appealing an automated review to avoid denial of the appeal/redetermination as not medically necessary. With the immediate implementation of these new procedures, provider concerns about 'duplicate' requests for records should be alleviated.
Last Reviewed: 09/28/2023
The RAC should send a retraction letter to the provider as well as a retraction file listing for the claims that need to be retracted to the Medicare Administrative Contractor (MAC). These two actions should occur at the same time. If an account receivable has been established on the affected claim(s), then the Finance Department will adjust down the demanded overpayment accordingly.
Although there is not an established timeframe to process retraction files, Palmetto GBA’s goal is to process a file within a reasonable timeframe. The retraction process is mostly manual so the total completion time varies dependent upon the size of the file received.
Last Reviewed: 09/28/2023
The N432 and N469 adjustment reason codes for Recovery Audit Contractors (RAC) adjustments will be normal adjustment reason codes. Reason codes will correspond to the RAC’s approved issues, which will be on RAC’s website.
Last Reviewed: 09/28/2023
The RAC appeal/redetermination process is the same as the regular appeal/redetermination process. All providers have 120 days from the date of the remit to file an appeal/redetermination. Please attach a copy of the denial letter, if you received one from the RAC, with your Request for Redetermination Form.
Last Reviewed: 09/28/2023
If a provider receives a RAC retraction letter, they should contact the Medicare Administrative Contractor (MAC) for status on their refund. If the MAC does not have a file for the closure, the MAC will follow up with the RAC. A provider should not contact the RAC.
Last Reviewed: 09/28/2023