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Written Inquiries Data

For provider inquiry analysis, CGS maintains a systematic and reproducible provider inquiry analysis program for written inquiries. We review the top reasons you write to us and use that information to develop and implement resources to address the needs of our providers.

Before you write to us, please be sure you are sending correspondence to the correct department and address. Check here to avoid misrouted written inquiries by selecting the "Mailing Addresses" icon.

One way to avoid misrouted written correspondence is to send your inquiries to us electronically through myCGS! If you have general questions regarding appeals, claims processing, finance, medical review, provider enrollment, or provider outreach, we encourage you to send them via myCGS. Check here for a job aid to help you navigate this myCGS function.

For your convenience, we also offer a comprehensive list of Frequently Asked Questions (FAQs). To save yourself some time, check the FAQs first!

Below is a list of the top reasons providers write to us.

Top Written Inquiries

Reason Resource/Reference

General Information: Incomplete Information Provided

When submitting inquiries, it is important that you include information needed to authenticate yourself, as this is a requirement of the Centers for Medicare & Medicaid Services (CMS). The data elements required to do this include:

  • Your National Provider Identifier (NPI);
  • Your Provider Transaction Access Number (PTAN);
    • Be sure to use the Group PTAN (when applicable). Individual PTANs are not used in the privacy verification process when a Group PTAN is assigned to the provider.
  • The last 5-digits of your tax identification number (TIN).

If your inquiry is specific to a Medicare patient, the following beneficiary information also needs to be authenticated:

  • The patient's Medicare Beneficiary Identifier (MBI)
  • First initial
  • Last name (first 6 letters); and
  • Date of birth

We cannot process inquiries submitted without these data elements.

Appeals: Duplicates

Appeals can take up to 45 days to process. Please avoid submitting duplicate requests.

Recently, we have sent dismissal letters to providers who have sent duplicate requests for Redetermination. To avoid this:

  • Use myCGS to send your requests for Redetermination. Information on this is located at myCGS User Manual - Appeals.
  • When completing the myCGS Redeterminations form, please verify that the ICN is specific to the claim you want to appeal.
  • Always select the Redeterminations form from the Claims tab, as the details of the claim will auto-populate on the form.

Always check the status of Redeterminations.

For information on ways to AVOID submitting Redeterminations to address Duplicate denials, please refer to Appeals Data Analysis.

Claim Denials: Frequency/Dollar Amount Limitation

Many services have associated limits in terms of the number of times they are paid and/or the dollar amount allowed. This information may be found in multiple places:

  • National Coverage Determinations (NCDs)
  • Local Coverage Determinations (LCDs)
  • Internet-Only Manuals (IOMs)

Use the Medicare Coverage Database (MCD)External Website to search for NCDs and LCDs. You may also locate our LCDs on the Medical Policies webpage.

There are also limitations on medically necessary therapy servicesExternal Website. Former therapy cap amounts are now thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary based upon documentation in the patient's medical record. Just as with the incurred expenses for the therapy cap amounts, there is one amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services.

This amount is indexed annually by the Medicare Economic Index (MEI). Claims for services over the KX modifier threshold amounts without the KX modifier are denied.

For CY 2023 this KX modifier threshold amount is:

  • $2,230 for PT and SLP services combined, and
  • $2,230 for OT services.

RTP/Unprocessable: Contractual Obligation (CO) Not Met

Services rejected with MA130 and a Contractual Obligation (CO) group code may not be billed to the patient.

  • For a comprehensive listing of group and remark codes, refer to the X12 web siteExternal Website

Rely on the CGS web site search engine to locate articles to address a number of issues

Check here on tips on improving search results when using our search engine!

Appeals: Status / Explanation/ Resolution

Providers and beneficiaries may appeal an initial claim determination when Medicare's decision is to deny or partially deny a claim.

To check the status of Redeterminations, refer to the following resources:

  • myCGSPDF: Redeterminations submitted through myCGS are assigned a Submission ID, which may be used to track its status.

Interactive Voice Response (IVR)PDF: Use the IVR to check the status of Redeterminations.

Claim Status: Payment Explanation/Calculation

CMS determines the amount allowed for all services paid from the Medicare Physician Fee Schedule (MPFS.) The formula used for the MPFS includes the following factors:

  • Work, Practice Expense (PE), and Malpractice (MP) Relative Value Units (RVUs)
  • Work, PE, and MP Geographic Practice Cost Indices (GPCIs)
  • Conversion Factor (CF)

Refer to the How to Use the MPFS Look-Up Tool MLN BookletExternal PDF for additional information and a reference to the CMS Physician Fee Schedule Search ToolExternal Website.

To find the CGS Jurisdiction 15 (J15) allowed amount of specific codes, refer to the CGS Part B Physician Fee Schedule Database. Select your state (KY or OH) and the year from the drop-down boxes. You may search for up to five specific codes or view the entire MPFS.

  • The amount located under the "Par" column is the allowed amount for a participating provider.
  • The amount in the "Non-Par" column is the amount allowed for a non-participating provider.
    • The Non-Par amount is 5% less than the Par amount.
  • Non-Par providers are limited in the amount they may charge for services, which is identified in the "Limit Charge" column.
  • The allowed amount noted with a '#' sign is reduced due to the Site of Service reduction.

Providers who render services in a facility setting do not incur the cost of overhead that they would in an office setting, therefore, the reimbursement is reduced.

Claim Denials: Evaluation & Management (E/M) Services

The CPT E/M code and guideline changes effective on and after Jan 1, 2021, were published by the American Medical Association. While most rules remain the same, there have been several revisions.

For CY 2023, CMS clarified and refined some policies specific to Other E/M visits, which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment. CMS also addressed the "substantive portion" definition. Check here for the CMS Fact Sheet summarizing E/M changes and updatesExternal Website.

For general E/M guidelines, both 1995 and 1997, please refer to the CMS E/M webpageExternal Website.

Claim Denials: Coding Errors/Modifiers

Call center staff cannot choose modifiers for you, as they do not have access to your medical records to ensure correct documentation is present.

  • Utilize the Modifier Finder Tool for help with correctly selecting and using modifiers.
  • Please be sure the documentation in the patient's medical record supports the use of any modifier added to a claim.

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