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 identified a minor error or omission when you first filed your claim. In this case, submit a reopening.
When a supplier submits a redetermination, CGS re-examines the initial claim decision.
- Suppliers must submit a redetermination within 120 days of the initial determination date on your Medicare Remittance Advice, Medicare Summary Notice, or Demand Letter.
- Suppliers should submit 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 submit your redetermination request is through the myCGS web portal.
- If you're already registered in myCGS, see the myCGS User Manual Chapter 7 – Redeterminations for step-by-step instructions.
- If you're NOT registered in myCGS, read this guide to get started.
You can also submit redeterminations by mail or fax. See the Supplier Manual, Chapter 13 for instructions on how to do so.
Resources:
- Redetermination Request Form Checklist – an overview of what you need before you submit
- Appeals Time Limit Calculator – helps you determine the last date you can submit a redetermination
- Appeals Decision Tree – helps you determine whether you should pursue a redetermination or a reopening
- Documentation Checklists
- If you're submitting by fax or mail (which is not the preferred method – see the DME myCGS portal), use the
- Submitting a redetermination request for an overpayment