When to File or Not File an Appeal
- Ambulance Denials. Note: Run sheets/tickets, Certification of Medical Necessity (CMN) and Physician Certification Statement (PCS) should be included to support each trip.
- Charges denied as Part A because the patient was seen in the office prior to admission in the hospital. Note: Documentation should be included to support the office service.
- Shared care denied for global service already on file. Note: Documentation of the shared care should be included to support the service billed.
- Claims denied as not medically necessary and the provider has supporting documentation to support the medical necessity.
- Procedures denied for exceeding Medically Unlikely Edits. Note: Documentation supporting medically reasonable and necessary units of service should be included with the request.
- Claims adjusted causing an overpayment may be appealed with the supporting documentation.
NOTE: Claims submitted with a GA modifier: must submit a valid signed ABN Advance Beneficiary Notice of Noncoverage (ABN) Form Instructions Tool and ABN Form Instructions
The above list is not an all-inclusive list of when to submit an appeal.
Do not submit a First Level Appeal for the following:
- Claims denied as return reject (MA130).
- Note: Do not send an appeal; a new claim must be submitted with the corrected information.
- Initial determinations past the 120 days redetermination (remittance advice) date, unless the reason for good cause qualifies per CMS guidelines.
- 2nd level appeals – do not send 2nd level appeals to CGS.
- Note: Send your second level appeal (Reconsideration) to the address noted on the letter for the Qualified Independent Contractor (QIC)
- Note: Send your second level appeal (Reconsideration) to the address noted on the letter for the Qualified Independent Contractor (QIC)
Updated: 12.17.2025
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