What to Send with a Redetermination Request
The CGS Redetermination department is noticing that there is an increase in the amount of documentation submitted with redetermination requests. The first step in responding to a claim denial is to review the reason for the denial. Use the myCGS Web Portal to learn why claims deny or in the case of a medical review denial use CGS Wizard to get a detailed denial reason.
Suppliers should only send in documentation in response to the denial reason and that which is necessary for payment. It is suggested that when a variety of documentation is submitted that suppliers separate the types of documentation with titled cover sheets. For example use a Detailed Written Order cover sheet in front of the Detailed Written Order that separates it from the Delivery Ticket, Lab Results, etc., which will have their own cover sheets. This extra step helps the redetermination reviewers quickly find the documentation needed to support payment for the claim. Examples of suggested cover sheets:
- Home Assessment
- Refill Request Documentation
- Delivery Documentation
- Certificate of Medical Necessity (CMN) or DME Information Form (DIF)
- Medical Records
- Documentation of Continued use
- Documentation of Continued Medical need
- Laboratory Tests/Results
- Face-to-face Medical Evaluation
- Other records
- Advanced Beneficiary Notice
- Repairs/Replacement Information
- Physician Signature Attestation
Remember to only send in what is necessary for claim payment. To see the complete list of documentation requirements visit the Documentation Checklist section and the Local Coverage Determination for the policy billed.
CGS has created the Documentation Identification Tool to assist you in submitting the different types of documentation needed to support your claim.
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