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CGS Administrators, LLC

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Medical Review

What Is Medical Review?

The Medical Review team is responsible for preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies. Medical review staff are licensed health care professionals providing a wide range of clinical expertise including, registered nurses and other clinicians. Dr. Robert D. Hoover, Jr., MD, MPH, FACP works closely with the Medical Review staff and helps oversee development and implementation of Local Coverage Determination (LCDs) and National Coverage Determinations (NCDs). This section provides detailed technical instructions to assist you in interpreting policy for documentation and billing purposes.

Medical Review Forms

PDF Forms, Checklists and Guides related to Medical Review can be found and downloaded here including ABN form, ADMC Request form, Refill Request Form, and more.

Medical Review Resources

CGS has created an extensive array of self-help resources including checklists for a variety of LCDs. Review this section for information about resources available to assist you in billing for DME.

Quarterly Reports

This section provides you with quarterly status reports on Medical Review's current service-specific pre-payment reviews. Review these reports for detailed information by policy group to see the claims payment error rates and top claim denial reasons for each product category.

Medical Review Pre-/post-payment Contractor Information

This section provides you with information regarding Zoned Program Integrity Contractors (ZPICs) and Medicare Contractor responsibilities and contact information.

About Robert Hoover, MD, MPH, FACP-Chief Medical Officer

Dr. Robert Hoover is the Chief Medical Officer for DME MAC Jurisdiction C. Review this section to learn more about his credentials and areas of responsibility at CGS.

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