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Redeterminations

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 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 web portal.

You can also send redeterminations by mail or fax. See the Supplier Manual, Chapter 13PDF for instructions on how to do so.

Resources:

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