
Submit a Redetermination
Suppliers and beneficiaries have the right to appeal claim determinations that the DME MAC made. (See Appeals Process for more details.) The first level of appeals is a redetermination.
A redetermination is a completely new, critical re-examination of a disputed claim or charge. Do not request a redetermination if you've found a minor error or omission when you first filed your claim. In this case, submit a reopening.
When a supplier sends a redetermination, CGS re-examines the initial claim decision.
- Suppliers must send a redetermination within 120 days of the initial determination date on your Medicare Remittance Advice, Medicare Summary Notice, or Demand Letter.
- Suppliers should send any new information or medical evidence.
- CGS has 60 days to complete a redetermination. If additional documentation is received, the processing time is 74 days from the date of the initial receipt.
The easiest and fastest way to send your redetermination request is through the myCGS DME web portal.
You can also send redeterminations by mail or fax using the Redetermination Request Form. See the Supplier Manual, Chapter 13
for instructions on how to do so.
Per IOM 100-4, Chapter 29, 240.3, CGS may find good cause for an untimely appeal due to unavoidable circumstances such as major floods, fires, tornados, and other natural catastrophes. When filing an appeal with CGS the following information is required:
- Beneficiary's name
- Beneficiary's Medicare Identifier (HICN/MBI)
- HCPCS codes
- Specific dates of service
- Printed name of the appellant or representative
- Signature of the appellant or representative
- Reason for the appeal
- If you were affected by a natural disaster and are unable to file a timely appeal, please include the following information in your appeal request: "Extension requested due to natural disaster exception and include the name of the natural disaster."
Resources:
- Appeals Time Limit Calculator – helps you find the last date you can send a redetermination.
- Appeals Decision Tree – helps you decide whether you should pursue a redetermination or a reopening.
- Submitting a redetermination request for an overpayment