February 21, 2025
Medical Review Reopenings
When a claim is subject to prepayment or postpayment review, CGS requests documentation for Medical Review to make a determination regarding coverage and payment. If the provider fails to submit the documentation within 45 calendar days of the request, the claim denies for non-receipt of requested medical records.
If CGS receives the requested information after the claim denies, Medical Review has discretion to reopen the claim. Medical Review will reopen a claim denied for non-receipt of requested medical records and make a medical review determination for the denied claim lines if we receive the requested documentation within 120 days after the claim denial date on the Remittance Advice.
Note: Medical Review won’t consider reopening a claim if there’s no new additional documentation to review. To request a review of the same documentation, you may submit a redetermination request (first level appeal).