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February 20, 2014 - Revised: 01.06.17

Redeterminations through myCGS: Reminders

myCGS, our secure web portal, will allow providers to submit requests for Redetermination (1st level of the appeal process) online, directly to CGS. In addition, supporting documentation may be attached to the request, which will be used when processing the redetermination.

When submitting RedeterminationPDF requests through myCGS, please remember the following:

  • Redetermination requests must be submitted within 120 days of the initial determination of the claim. The initial determination date is based on the date of the Medicare Remittance Advice (RA.)
  • Claims that were never submitted to Medicare have no appeal rights
  • Claims in a suspended status (i.e., not yet finalized) cannot be appealed. Instead, please call the Provider Contact Center for assistance.
  • Please be sure your redetermination request is valid. Examples include:
    • Claims denied as not medically necessary and the provider has supporting documentation to support medical necessity
    • Services that have been denied due to frequency limitations
    • If you dispute the liability for the denied or non-covered services (e.g., the claim was denied as a contractual obligation, but you have a valid Advance Beneficiary Notice of Non-coverage (ABN) on file)
    • Overpayment demands or offsets
    • CPT modifiers 24, 25, 58, 78, or 79 are being added to support an exception to the global surgery package (supporting documentation is required)
    • For Ambulance denials, include a copy of the run ticket to support each trip, along with any other supporting documentation you feel is helpful
  • You must attach at least one document to the myCGS Redetermination request form.
    • If you have no documentation to attach, please attach a copy of the remittance advice (RA).
    • Attachments must be in a PDF format and may be up to 40MBs in size, not to exceed a total of 150MBs for all attachments.

If you need assistance determining whether a request for redetermination is valid or have additional questions, please call our Provider Contact Center at 866.276.9558.

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