Redeterminations Ask the Contractor Meeting (ACM) – July 15, 2026
The following questions and answers are from the CGS Jurisdiction B and Jurisdiction C ACM on July 15, 2026. During the meeting we reviewed Redetermination data and explained the most frequent reasons for appeals.
We summarized and edited the questions and answers for clarity. The answers were accurate at the time posted.
Questions and Answers
- We received a favorable reconsideration decision. We have newer claims that we didn't appeal while waiting for this decision. They are now past-timely for appeals. Can an exception be made for being past timely filing?
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Answer: We will consider past timely appeals on a case-by-case basis.
For more information about good cause for late filing, see CMS Internet Only Manual (IOM) 100-4, Chapter 29, Section 240
. - Medicare hasn't established an allowable amount for J7131 (hypertonic saline). Do we need to provide a cost invoice when appealing denied claims for this drug?
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Answer: CGS has now set a fee for J7131. Any claims that were denied for missing pricing information can be resubmitted. You do not need to file an appeal.
**This information was researched after the call, and the answer has been updated to show the current process.
- If my PTAN was revalidated or updated and is now showing as suspended, what is the process to get it reactivated?
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Answer: Contact the appropriate NPE contractor based on your location (east or west of the Mississippi) to restart the process. After that, if your PTAN is reinstated, CGS will automatically reprocess your claims.
- How can we prevent future denials for "12‑month document" issues when refill confirmations are already included to show continued use?
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Answer: You must have both continued medical need documented in the treating practitioner's records and continued use documented in the supplier's records. Both elements are required for the claim to be supported.
A refill confirmation alone isn't enough. Under Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
for continued need, you must have a recent order or prescription for supplies or repairs, a recent change in the order, or timely medical record documentation of usage. In other words, continued need requires an actual order, not just a refill request. - Ultra‑light material codes are denying because they're splitting from the base prosthesis code. Is this something that requires a redetermination, or can it be corrected by calling in the issue?
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Answer: The claim can be appealed for payment.
Follow-up: To prevent this issue, bill the base code on line one and the code for ultra-light weight material on line 2.
- Pharmacies dispensing CGMs are receiving audit denials stating that medical records don't support continuous or repeated use of the devices. Do you have any insight into why these audits are denied or what documentation is required?
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Answer: The Glucose Monitors Local Coverage Determination (L3382)
requires the following for continued coverage:- Every 6 months following that initial prescription, the treating practitioner must conduct an in-person, or Medicare approved telehealth visit with the beneficiary to document adherence to their CGM regimen and diabetic treatment plan.
- If this criterion is not met, claims for ongoing CGM supplies will be denied as not reasonable and necessary.
- We have a patient who no longer qualifies for a Medicare covered pressure reducing support surface (PRSS) after flap surgery. They want to privately pay for the PRSS. Do we need an ABN to remain compliant with Medicare rules?
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Answer: Yes. The patient should complete an ABN. The ABN protects your organization in case the patient later asks you to submit the claim to Medicare, despite choosing to pay privately. Completing the ABN documents that the patient understands Medicare is unlikely to cover the item and that they are agreeing to pay out‑of‑pocket.
If you need guidance on how to properly complete the ABN, we have an ABN Form Instructions Tool that walks you through each step.
7b. How long is the ABN valid? To clarify, this is for the E0194.
Answer: An ABN stays valid for the rest of the rental period as long as nothing important changes, including:
- The type of care the patient is receiving stays the same as what was described on the first ABN.
- The patient's health doesn't change in a way that would require different treatment for the condition Medicare doesn't cover.
- Medicare's rules for covering that item or service have not changed.
You may find this information in the Claims Processing Manual 100-04 of the Internet Only Manual, Chapter 30
. - For orders written for a 3‑month supply, we still receive denials even when the redetermination specifies the 90‑day quantity. When reviewers check these claims, are they looking at previous billing history to determine whether the patient exceeded the allowed units within the 3‑month period?
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Answer: Yes. Our reviewers check past claims to see if the patient is getting more supplies than allowed in a 90-day period. We would need examples to help us understand why the specific claims were denied.
- We submitted a Medicare claim for prosthetic repairs, including two L7510 codes and associated labor. One repair was paid, one denied, and the labor was split and partially denied. Should we submit a redetermination, or is it better to call Medicare first to understand why this happened?
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Answer: It is your option whether to contact customer service for more information. If your records show the claim meets Medicare guidelines, submit a redetermination. Include any additional information Medicare has requested to prevent further delays.
- I submitted 3 redeterminations for a patient's glucose meter, strips, and lancets. All 3 were routed to reopenings, but only the meter shows as completed. The strips and lancets still say, transferred to reopenings. However, nothing appears in the reopenings status. How does this process work?
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Answer: We recommend calling Customer Service to get more information about the reason for delay in processing:
- Jurisdiction B: 866.590.6727
- Jurisdiction C: 866.270.4909
- A patient already has an E0260 (Hospital bed, semi-electric, head and foot adjustment, with any type of side rails, with mattress) from another supplier. The physician prescribed an E0277 (Powered pressure-reducing air mattress).
In these cases, we contact the other supplier for pickup. Often, the supplier doesn't pick up the equipment for months, causing denials for the E0277.
We appealed a claim at the Administrative Law Judge (ALJ) level. We were told Medicare still wouldn't pay since the E0260 was previously covered, and that we should contact the DME MAC about the issue. If we've done everything required and still have denials, what steps should we take when ALJ says nothing more can be done?
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Answer: You have the option to file an appeal of the ALJ decision with the Departmental Appeals Board (DAB).
For future claims, if the supplier will not change the way they are billing, you may need to ask the beneficiary to contact the supplier who is billing for the hospital bed.
You can also issue an ABN and make sure the beneficiary understands they may be responsible if the other supplier doesn't stop billing the bed with the mattress.
See the Hospital Beds and Pressure Reducing Support Surfaces – Billing Instruction article for more information.
Reviewed: 08.12.2026
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