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CGS Administrators, LLC

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Medical Review

The mission of Medical Review (MR) is to reduce supplier billing errors and ensure that Medicare claims are paid correctly while maintaining the Medicare Program integrity. To reduce claim submission (coverage/coding) and payment errors, and increase timely payments, data is gathered and errors are identified and addressed.

The CGS Medical Review department consists of a Medical Director, registered nurses and other clinicians, and specially trained support staff. To achieve the goals of CMS's MR program, CGS Medical Review:

Medical review activities performed at CGS also include processing Advance Determination of Medicare Coverage (ADMC), Prior Authorization, and CGS Connect requests.

Targeted Probe and Educate (TPE)

Targeted Probe and Educate (TPE) – View Information on the TPE review process.

TPE Quarterly Reports by Policy

TPE Quarterly Reports by PolicyView details about Service Specific Post-Payment Reviews and/or Pre-Payment Reviews from last quarter, used to determine extent of potential problem areas across multiple suppliers and monitor corrective action measures implemented to reduce improper payments


Advance Determination of Medicare Coverage (ADMC)Information about Advance Determination of Medicare Coverage (ADMC)


Prior AuthorizationInformation about Prior Authorization (PA)

Physician's Corner

Physician's CornerThe Physician's Corner is specifically designed for the benefit of physicians and practitioners who prescribe DMEPOS items for Medicare beneficiaries.

Education Programs

Education ProgramsAbout individualized services CGS Xchange and CGS Connect, programs to help reduce claim denial rates.

LCDs/Policy Articles

LCDs/Policy Articles

Medical Review Forms

Medical Review FormsLinks to helpful PDF forms such as ADMC, Prior Authorization and various CMNs.

Tools: CGS Wizard and ADR Tool, TSD Timeline

Tools: CGS Wizard, ADR Tool, Condition of Payment Prior Authorization Lookup, TSD Timeline

Medical Review Resources

Medical Review Resources

DME MAC Joint Publications

DME MAC Joint Publications

Serial Claims Review Initiative

Serial Claims Review Initiative – View information about the serial claims review initiative.

Other Medical Review Contractors

Other Medical Review Contractors

Artificial Limbs, Braces, Other Custom Made Items

Artificial Limbs, Braces, Other Custom Made Items

About Robert Hoover, MD, MPH, FACP – Chief Medical Officer About Robert Hoover, MD, MPH, FACP – Chief Medical Officer
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