Appeals Decision Tree
Answer the questions below for guidance on next steps regarding appeals/redeterminations and reopenings.
1. Is this claim for an overpayment appeal?
2. Has your claim appeared on a remittance advice?
Yes No
Do not take any action until you receive a Medicare Remittance advice with notice your claim is complete.
3. Does the Remittance Advice show that your claim has been rejected as unprocessable with MA-130?
Yes No
4. Was everything correct on the claim you submitted?
Yes No
You will need to request a reopening or claim correction (as appropriate). For more information on reopenings and claim corrections, visit https://www.cgsmedicare.com/pdf/dme/dme_reopenings_chart.pdf
.
The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on requesting a reopening, visit https://www.cgsmedicare.com/jc/claims/reopenings.html.
5. Have you filed a redetermination on this claim previously?
Yes No
6. Have you received your decision?
Yes No
File a reconsideration request with the Qualified Independent Contractor (QIC), or vacate the dismissal with CGS. For information on requesting a reconsideration, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html
Please allow 60 days for completion. You can check the redetermination status in myCGS or by calling the IVR.
The fastest and easiest way to get your redetermination status is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html
6. Did your claim deny for untimely filing?
Yes No
Your claim is not eligible for appeal. If you feel you have good cause to reopen your claim, submit a reopening request.
The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on requesting a reopening, visit https://www.cgsmedicare.com/jc/claims/reopenings.html.
7. Is the date of the initial determination or demand letter within 120 days?
Yes No
Your appeal rights have expired. If you have sufficient reason for filing the redetermination request past timely, please provide good cause with your redetermination request.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
Additional information on filing a redetermination request can be found here: https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
8. Does your claim involve Medicare Secondary Payer (MSP)?
Yes No
9. Are you a proper party to the initial determination?
Yes No
10. Are you an appointed representative appealing on behalf of the provider or beneficiary?
Yes No
You are not eligible to file an appeal for this claim.
File a redetermination request, and include a completed Appointment of Representative Form.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
This claim is eligible for appeal. Submit a redetermination request.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
9. Was your claim denied due to missing MSP information?
Yes No
10. Are you a proper party to the initial determination?
Yes No
11. Are you an appointed representative appealing on behalf of the provider or beneficiary?
Yes No
You are not eligible to file an appeal for this claim.
File a redetermination request, and include a completed Appointment of Representative Form
.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
This claim is eligible for appeal. Submit a redetermination request.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
For claims that have been denied for no MSP information, or if the MSP record has been updated, submit a reopening request.
The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on requesting a reopening, visit https://www.cgsmedicare.com/jc/claims/reopenings.html.
This claim is unprocessable and has no appeal rights. Please submit a new claim with the complete/correct information.
2. Has your claim appeared on a demand letter?
Yes No
Do not take any action until you receive a demand letter. For more information about appealing an overpayment, visit https://www.cgsmedicare.com/jc/claims/appeals/appeal.html.
3. Was everything correct on the claim you submitted?
Yes No
You will need to request a reopening or claim correction (as appropriate). For more information on reopenings and claim corrections, visit https://www.cgsmedicare.com/pdf/dme/dme_reopenings_chart.pdf.
The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on requesting a reopening, visit https://www.cgsmedicare.com/jc/claims/reopenings.html.
4. Have you filed a redetermination on this claim previously?
Yes No
5. Have you received your decision?
Yes No
File a reconsideration request with the Qualified Independent Contractor (QIC), or vacate the dismissal with CGS. For information on requesting a reconsideration, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html
Please allow 60 days for completion. You can check the redetermination status in myCGS or by calling the IVR.
The fastest and easiest way to get your redetermination status is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html
5. Did your claim deny for untimely filing?
Yes No
Your claim is not eligible for appeal. If you feel you have good cause to reopen your claim, submit a reopening request.
The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on requesting a reopening, visit https://www.cgsmedicare.com/jc/claims/reopenings.html.
6. Is the date of the initial determination or demand letter within 120 days?
Yes No
Your appeal rights have expired. If you have sufficient reason for filing the redetermination request past timely, please provide good cause with your redetermination request.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
Additional information on filing a redetermination request can be found here: https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
7. Does your claim involve Medicare Secondary Payer (MSP)?
Yes No
8. Are you a proper party to the initial determination?
Yes No
9. Are you an appointed representative appealing on behalf of the provider or beneficiary?
Yes No
You are not eligible to file an appeal for this claim.
File a redetermination request, and include a completed Appointment of Representative Form.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
This claim is eligible for appeal. Submit a redetermination request.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
8. Was your claim denied due to missing MSP information?
Yes No
9. Are you a proper party to the initial determination?
Yes No
10. Are you an appointed representative appealing on behalf of the provider or beneficiary?
Yes No
You are not eligible to file an appeal for this claim.
File a redetermination request, and include a completed Appointment of Representative Form.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
This claim is eligible for appeal. Submit a redetermination request.
The fastest and easiest way to submit a redetermination request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on filing a redetermination request, visit https://www.cgsmedicare.com/jc/claims/appeals/5levels.html.
For claims that have been denied for no MSP information, or if the MSP record has been updated, submit a reopening request.
The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. For more information on the DME myCGS web portal, visit https://www.cgsmedicare.com/jc/mycgs/index.html.
For additional information on requesting a reopening, visit https://www.cgsmedicare.com/jc/claims/reopenings.html.
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