License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
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The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

Appeals

Redeterminations

If looking for information concerning Part B Reopenings, please refer to 'Forms section' for Part B Reopenings.

Providers and beneficiaries may appeal an initial claim determination when Medicare's decision is to deny or partially deny a claim. The first level of the appeal process is Redetermination. You have 120 days from the date of receipt of the notice of initial determination to submit a request. There is no monetary threshold.

Providers may submit Redeterminations through myCGS. The Redeterminations form is available under the Claims tab provided the time limit to submit a request has not expired.

To access claim information:

Select the “Claims”tab. The “Claim Status Inquiry”page will display.
From the drop-down box, select Medicare ID to enter the patient’s Medicare Beneficiary Identifier (MBI).
- Enter a date of service in the MM/DD/CCYY format.
Instead of searching by Medicare ID, you may select Claim Number from the drop-down.
- Enter the Internal/Document Control Number (ICN/DCN) in the field.
- Please note, there will be times when the original ICN/DCN of the claim will not display. An example of this is when the claim has been adjusted, in which case the adjustment number will display instead. Please search using the MBI option.

NOTE: Retrieving claims information older than six months may take additional time. In addition, offline claims will not be displayed. Many claims are offline after three years, sometimes earlier.

Click “Submit.”

CSI Screen

Select the Claim # link to display the details of the claim. To submit a Redetermination, the claim must be finalized.

CSI List

The “Detailed Claim Status Information” page provides information specific to the claim. Below the line item details you will find the various functions and forms that may be submitted for the claim. If within time limit (120 days of the initial determination), the “Request Redetermination” button will be available.

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Refer to the Detailed Claim Status Information section under the Claims tab for additional information.

Once the form loads, please note that fields with a RED asterisk (*) are required, most of which will auto-populate. This includes the beneficiary, provider and claim information.

The specific service(s) being appealed must be added to the form by entering them into the “Denied CPT/HCPCS & Modifiers” field.
Click the “Add” button to populate the appropriate box.

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After entering each code, click the “Add Claims Information” button to add the line to the form.

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Identify whether the request is to appeal an overpayment.
There is also an area to explain the reason you are submitting the redetermination request. This field will hold up to 1200 characters.

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Upload at least one attachment to be sent with the request to support the service(s) being appealed. You can attach up to 10 documents. Attachments can be up to 40MBs in size, not to exceed to total of 150MBs for all attachments. The documents must be in a PDF format.

Click on the “Choose File” button and a window will open allowing you to locate and attach the PDF document to the form. Each attachment will populate in the “Attached Files” window.

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Enter the name of the person requesting the redetermination. Click the “Submit” button when the form is complete and ready to be submitted. The date will auto-populate.

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An alert and ‘e-signature’ box will appear, asking you to verify that the information entered and attachments are all correct. This ensures the signature requirement for submitting a redetermination request have been met.

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If the information was entered correctly, and all desired attachments were included, click ‘OK’ to submit the form and all attachments.

If corrections need to be made to the form or if any attachments need to be added or deleted, click ‘Cancel’ to return to the form.

Shortly after submission, you will receive a message confirming receipt of the Redetermination request. A separate message will be sent to your inbox, which will include a Submission ID assigned to your request. The Submission ID may be used to track the status of your request.

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Please refer to the Messages tab of the myCGS User Manual for more details.

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Checking Redetermination Status

HHH, Part A, and Part B users may check the status of an appeal from the “Get Status” button.

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Enter the Submission ID assigned to the form for a general status. The status page will show the current status of the request in addition to the details submitted on the redetermination.

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Or, all users can click on the Submission ID located in the confirmation received in your Messages inbox. myCGS will display the same information as above.

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Part A and HHH Users

For Part A and HHH users, Appeals status is also displayed under the Claims tab in myCGS. To view the status of an appeal:

Access the claim information under the Claims tab.
The Claim Status Information page will display. Click on the claim number to view the claim details.

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The Detailed Claim Status Information page identifying the claim information will display an Appeals window. If a 1st level appeal, Redetermination, has been requested on the claim, you will see this window populate.

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In the Appeals window, you will see:

The level of appeal requested.
The status of the appeal and, if complete, the date the case was closed.
The appeal number assigned to the case.
Option to perform other functions, depending upon the appeal status and decision.

If the Redetermination is in a "Closed" status and the decision is Unfavorable, Partially-Favorable, or a dismissal, you may view the letter sent to you explaining our decision by clicking on the "View Decision Letter" link.

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The decision letter is a PDF of the letter you receive via Green Mail or hardcopy.

NOTE: A Fully-Favorable decision will not generate a letter. Please refer to your Remittance Advice to find the adjustment.

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Submitting a 2nd Level Appeal (A/HHH)

Part A and HHH users may use myCGS to submit a request for Reconsideration, the 2nd level of the Appeal process. An Appeals window allows user to track the 1st and 2nd level appeals requested on the claim.

From the Claim Status Information page, click on the claim number to view the claim details.

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The Detailed Claim Status Information page identifying the information submitted on the claim now displays an Appeals window. If a 1st level appeal, Redetermination, has been requested on the claim, you will see this window populated.

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This is a convenient way to track the appeal requests submitting for this claim. It identifies:
- The level of appeal requested.
- The status of the appeal and, if complete, the date the case was closed.
- The appeal number assigned to the case.
- Option to perform other functions, depending upon the appeal status and decision.

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NOTE: A Fully-Favorable decision will not generate a letter. Please refer to your Remittance Advice to find the adjustment.

The decision letter is a PDF of the letter you receive via Green Mail or hardcopy.

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If you disagree with the decision of your Redetermination as noted in the decision letter, you may request a Reconsideration of the Qualified Independent Contractor (QIC). The QICs for our jurisdiction are C2C Innovative Solutions, Inc. (C2C) and Maximus.

Your request for Reconsideration may be submitted through myCGS! This is done by selecting the Submit a 2nd Level Appeal button located in the lower-right corner of the Appeals window.

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