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January 25, 2019

Appeals Process – Tips and Reminders!

This reminder article about filing Redeterminations and the appeals process also includes some answers to common questions and tips to help assure you have all of the information you need when you submit a Redeterminations request to CGS.

Why does it take a few weeks before we know the outcome of the Redetermination request?

When a Redetermination is received from a supplier, it goes into our workload queue. All of the cases are worked on a first come-first serve basis. For example, any cases we received on January 9, 2019, will be worked and completed before cases received January 10, 2019. Our CMS requirement is to complete a Redetermination within 60 days of receipt and we are currently completing our workload in far fewer than 60 days.

Can the claim be appealed?

When you receive the Medicare Remittance Advice, verify the claim in question is actually denied and not rejected by the system. One of the most common ANSI codes we see is "CO-16," which means that some information was missing on the claim when it was originally submitted. These rejected claims do not have appeal rights and must be resubmitted to the DME MAC after the error or missing information has been corrected.

We have a new tool on our website to assist you with researching claim denials, the Claim Denial Resolution Tool. Use this handy option before you file a Redetermination!

How do I know what documentation to send to Redeterminations?

If you aren’t sure why a claim denied, you should input the Claim Control Number (CCN) into the CGS Wizard on either the Jurisdiction B or Jurisdiction C website. The CGS Wizard will provide you with information on why the claim denied by listing all of the reasons for the denial.  You can then determine what pertinent documents to submit to Redeterminations.

Here’s a helpful scenario. CGS Medical Review denies a semi-electric hospital bed claim during a Targeted Probe and Educate (TPE) audit. The supplier checks the CGS Wizard (see example below) when they notice the denial on the remittance statement and sees the claim was denied for not providing proof of delivery. A staff member opens the Medicare beneficiary’s file and sees that the beneficiary has rented a manual wheelchair and a nebulizer from them in the past. As they page through the file, they find the proof of delivery for the hospital bed placed in with the nebulizer documents. Since the claim was for a hospital bed, the supplier needs to send only the completed Redetermination Request Form and the proof of delivery documentation for the hospital bed denied claim. There is no need to send old medical records related to other DMEPOS items or other documents (i.e., orders or signed Assignment of Benefits form) for the hospital bed. When our Redeterminations analysts receive the documentation, they will look for evidence to refute the denial so the claim can be adjusted and paid.

Here is the CGS Wizard. Simply input the 14-digit CCN and click "Submit." It’s that easy!

Screen Shot

Is the Redetermination Request Form necessary?

There are specific elements that must be present on a Redetermination request in order for the DME MACs to complete the case. If any of those elements are missing, we must dismiss the request, but we will send you a letter to inform you of the dismissal. The easiest way to have all required elements on a request is to use the Redetermination Request FormPDF. If completed in its entirety, you are guaranteed that all required elements are present. If you prefer to submit a written request, here is the list of elements that must be with every Redetermination request:

We also recommend including all of the CCNs in question so we won’t miss any dates of service you want reviewed.

Do I need to put anything in the "Reasons/Rationale" section?

Keep in mind Redeterminations analysts have not seen this claim or any documentation that goes with it until they are ready to work that individual Redetermination case. Adding comments to help our analysts know what you want us to do can only help the outcome. Brief statements such as, "Please adjust," or "Here is that page," don’t provide the information needed to process the Redetermination. Provide specific statements or direction on what you want us to look for. Using our scenario above, this would be a great comment in the Reasons/Rationale section of the Redeterminations Request Form: "This claim denied in a TPE audit for missing POD. Please see the signed proof of delivery and adjust the claim to pay." This brief statement tells the analyst what happened, what you sent, and what you would like us to do with the claim as part of the Redetermination.

Can I file Redeterminations from Overpayment Demand Letters that I receive?

Yes, you can. In addition to denials you might receive from initial claim submission, other auditing entities will review claims after they have been processed and paid (CERT, RAC, or SMRC, for example).  If you receive an overpayment demand letter from one of the post-pay auditing contractors, you do have appeal rights for that claim.  Submit a Redetermination request to the DME MAC that processed the original claim. When completing the Redetermination Request Form, select "YES" and the appropriate auditing entity in the overpayment appeals section of the form. Include the overpayment demand letter and any supporting documentation to refute the reason(s) for denial.

How do I send documents to Redeterminations?

CMS requires that Redetermination requests be made in writing. CGS will accept documents submitted through your esMD (Electronic Submission of Medical Documentation) gateway, through the U.S. mail or via fax. For your convenience, here are the fax numbers and mailing addresses for both Jurisdiction B and Jurisdiction C. Please note there are separate numbers and addresses for overpayment appeals.

Jurisdiction B (Redeterminations):

Fax: 1.615.660.5976
Mail: CGS, PO Box 20007, Nashville, TN 37202

Jurisdiction B (Redeterminations for Overpayment Appeals):

Fax: 1.615.782.4514
Mail: CGS, Overpayment Appeals, PO Box 23070, Nashville, TN 37202

Jurisdiction C (Redeterminations):

Fax: 1.615.782.4630
Mail: CGS, PO Box 20009, Nashville, TN 37202

Jurisdiction C (Redeterminations for Overpayment Appeals):

Fax: 1.615.664.5907
Mail: GS, Overpayment Appeals, PO Box 23917, Nashville, TN 37202

What should I do if my claim is still denied after a Redetermination decision?

A Redetermination filed to the DME MAC is the first step in the appeals process.  When necessary, there are other levels of appeals that can be followed. They are Reconsiderations, Administrative Law Judge (ALJ) Hearing, Departmental Appeals Board Review and Federal Court Review.

Here are some tips and reminders when filing a Redetermination to CGS:

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