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1st Level of Appeal – Redetermination

Physicians, suppliers, and beneficiaries have the right to appeal claim determinations made by MACs. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by MACs are governed by the Centers for Medicare & Medicaid Services (CMS). As a MAC, CGS handles the first level of appeal, redetermination requests. There are five levels of appeal.

Redetermination Form / Job Aids

Time Limit for Filing Request

120 days from the date of receipt of the notice of initial determination

Monetary Threshold to be Met


Helpful Tips

  • Always submit the Appeal form as the top document in the appeal submission for faster processing.
  • Appellants have the opportunity to submit any and all supporting documentation with their appeal. Legal briefs can be submitted, but are not necessary for the appeal review and do not increase the likelihood of a favorable outcome.
  • If filing a single appeal with multiple beneficiaries for Part A and HHH, utilize the Multiple Beneficiary/Single Appeal Request SpreadsheetPDF. This will aid in the review process. If appealing a UPIC decision, the UPIC notification letter is not the best practice to submit as the list of claims being appealed.
  • As of July 8, 2019, CMS no longer requires a signature on an appeal form.
  • CGS has 60 days to process an appeal.
  • If you are a Provider, you can sign up to receive your redetermination notices via the myCGS Portal. The notices are available in the portal the same day. For more information, refer to the Opt In/Opt Out of Greenmail job aid. 

The beneficiary or their representative may request an appeal on any service processed for them. Provider and Suppliers may appeal services for which assignment was accepted. For unassigned claims, providers/suppliers may act as the beneficiary's representative if the beneficiary signs an authorization statement (such as form CMS-1696External PDF). In addition, provider/suppliers may request a redetermination on an unassigned claim if Medicare B denied the service as not reasonable and necessary or the provider/supplier billed in excess of the Limiting Charge and the provider/supplier is required to refund any fees collected from the beneficiary.

Additional Resources:

Updated: 12.08.23


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