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Appeals

Attention: CGS encourages suppliers to use the MBI for all workloads. However, there are a few exceptions when you can use either the HICN after January 1, 2020, if you are unable to obtain the MBI. You should use the MBI for your appeal if available, but are allowed to use HICNs for claim appeals and related forms if the MBI is unavailable.

What is an Appeal?

An Appeal is your opportunity to formally question how your claim was processed and/or paid. Use this section to review the Appeals options available to you.

The 5 Levels of the Appeals Process

The Medicare program gives you the right to appeal a claim decision. This section provides detailed information on Redeterminations, Reconsiderations, Administrative Law Judge (ALJ), Departmental Appeals Board (DAB) Reviews and the Federal Court (Judicial) Review.

Appeals Timelines

CMS has established specific timelines for each of the 5 levels of the appeal process. If you are planning to appeal a claim decision, use this section to locate timeliness requirements.

 
How Do I Appeal An Overpayment?

This section provides important instructions on how to properly appeal an overpayment.

Appeals Forms and Tools

We have created a variety of tools and forms to help you file your appeal in a timely manner. Use this section to locate the various online tools of benefit in your appeals process.

What to Send with a Redetermination Request

The CGS Redetermination department is noticing that there is an increase in the amount of documentation sub mitted with redetermination requests. The first step in responding to a claim denial is to review the reason for the denial. Use the myCGS web Portal to learn why claims deny or in the case of a medical review denial use MR Wizard to get a detailed denial reason. Both tools can be found online at www.cgsmedicare.com.

Where Do I Send my Appeal?

Each level of appeal has a specific address and/or fax number. Use this section to locate the address and other relevant contact information for your specific level of appeal.

Misdirected Redeterminations Delay Processing and Timely Decisions

The CGS Jurisdiction C, DME MAC Redeterminations Department receives a significant volume of misdirected requests every month. Ensuring that you send your redetermination requests to the correct contractor reduces processing time, ensuring that you will receive a decision in a timely manner, and also reduces administrative costs to the Medicare program.

 
Appeals Education

The CGS Provider Outreach and Education (POE) team has created a variety of education programs specific to the Appeals process. If you are new to Medicare or simply wish to refresh your knowledge of the various Appeals processes, we have provided a list of education for you. Use this section to review the types of education available.

Reconsiderations: Formal Telephone Discussion Demonstration

CMS launches a Formal Telephone Discussion Demonstration with Durable Medical Equipment (DME) suppliers in Jurisdictions A, B, C, and D that submit Medicare Fee-For-Service claims. The demonstration will provide selected suppliers that have submitted reconsiderations (second level appeal requests) the opportunity to participate in a formal recorded telephone discussion with the DME Qualified Independent Contractor, MAXIMUS Federal Services Additional information regarding the demonstration can be found at MAXIMUS Federal ServicesExternal Website.

Appeals Decision Tree

Do you need to submit a request for redetermination or request a reopening? Use the Appeals Decision Tree for guidance on the correct action to take.

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