myCGS User Manual

The "Forms" tab allows providers to submit certain types of requests directly to CGS through the myCGS web portal safely and securely. Most forms are pre-populated with information specific to your account, reducing the amount of time it takes to complete and submit them. You are also able to attach additional documentation that will be used for processing.

Forms Available in myCGS

The forms available in myCGS may vary based on your line of business (i.e., Part A, Part B, Home Health, Hospice). They include the following:

Part A	Part B	Home Health	Hospice
Redeterminations	Redeterminations	Redeterminations	Redeterminations
Audit & Reimbursement Secure Messaging	Reopenings	Audit & Reimbursement Secure Messaging	Audit & Reimbursement Secure Messaging
Comparative Billing Report	Comparative Billing Report	Comparative Billing Report	Comparative Billing Report
Response to Medical Review Additional Documentation Request	Response to Medical Review Additional Documentation Request	Request for Anticipated Payment Comparative Billing Report	Response to Medical Review Additional Documentation Request
General Inquiry	General Inquiry	Response to Medical Review Additional Documentation Request	General Inquiry
Credit Balance*	Immediate Offset*	General Inquiry	Credit Balance*
Immediate Offset*	Part B Claim Submission**	Credit Balance*	Immediate Offset*
Reconsiderations**	Overpayment Recovery Request	Immediate Offset*	Reconsiderations**
Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services	Prior Authorization (PA) of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT)	Reconsiderations**
Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services (Part A) Exemption Opt-Out

* Form is located under the "Financial Tools"tab

** Form is located under the "Claims"tab

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Accessing myCGS Forms

Select the Forms tab to access the Secure Forms page.

Once on the Secure Forms page, you will find an option to Select a Topic.  Options in the drop-down box include Redeterminations, Reopenings (for Part B), Audit and Reimbursement (for Part A and HHH), Medical Review, Provider Contact Center, Overpayment (for Part B), and Prior Authorization.

You may have to select an option under the Select a Type drop-down, as some topics have multiple types of forms.  Once selected, click on the link to the form.

NOTE: Provider Administrators have access to all tabs within myCGS.  Provider Users have access to only the tabs the Provider Administrator has granted permission to access.  If you have access to the forms available in myCGS, the ‘Forms,’ ‘Financial Tools’ and ‘Claims’ tabs will be visible once you successfully log into the portal.  If a tab is grayed out, but you believe you need access to the tab, contact your Provider Administrator.

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Completing a Form

You will find the form you select is pre-populated with information specific to your account including the provider's name, PTAN, and NPI. Complete the remaining fields of the form. Those fields that are required are marked with a RED asterisk (*).

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Redeterminations

Providers and beneficiaries may appeal an initial claim determination when Medicare's decision is to deny or partially deny a claim. The first level of the appeal process is Redetermination. You have 120 days from the date of receipt of the notice of initial determination to submit a request. There is no monetary threshold.

Note: Access this form from the Claims tab to ensure the form correctly auto-populates with the information we need to process your request.

Refer to the Appeals section of this manual for step-by-step instructions on how to complete and submit Redeterminations.

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Reopenings (Part B)

Part B Reopenings may be submitted to correct minor errors and omissions on previously processed claims. Requests must be submitted within 12 months of the original claim remittance date. Only one claim can be corrected per form.

After selecting the Reopenings form it will load auto-populated with the provider information. Add any missing information to the form.

Enter the patient's name and Medicare Beneficiary Identifier (MBI) in the Beneficiary Information section.

Under the Claim Information section, enter the claim Internal Control Number (ICN). The ICN is located on the CGS remittance advice (RA).

Next, under Type, click the drop-down box to select the type of reopening you wish to submit. Refer to the instructions below for the various types of Part B reopenings.

When the form is complete, click the Submit button to file your reopening request. If you need some additional time to complete the form, click Save. To find the saved form go to the Saved Forms sub-tab, which is located under the Messages tab.

Click on a heading to expand/close it.

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Audit & Reimbursement

Home Health, Hospice, and Part A providers are required to submit financial data, which support amounts claimed in a cost report, directly to CGS. This financial information is reviewed and processed by our Audit & Reimbursement (A&R) team.

This sensitive information and other correspondence may be submitted securely through myCGS.

NOTE: Per the Centers for Medicare & Medicaid Services (CMS), cost report submissions are no longer accepted through myCGS. Please refer to MLN Matters® article MM10611 for more on submitting cost reports.

After clicking the “A&R Correspondence: AR-J15-HHH-7010” link and the form loads, the Provider Information section will auto-populate.

• From the 'Fiscal Year End Date' field, select the date from the calendar icon or enter the fiscal year end date in the XX/XX/XXXX format.

  

• Enter the name of the specific CGS employee for whom the correspondence is being sent.
• In the 'Workload' field, click the drop-down box to select the subject of your correspondence. The options available are:
  • Tentative Settlement/Rate Review/PIP – Used to determine a tentative settlement after a cost report is submitted. A Rate Review and Periodic Interim Payment (PIP) are reviews to determine a rate to pay the provider.
  • Desk Review/Audit – Reviews to determine the accuracy of the cost report for final settlement.
  • Wage Index – A review of wages used by CMS to establish the wage index amounts used to calculate payment of claims.
  • Reopening – A review of issue(s) from a cost report that has been previously settled. This review is subsequent to a request received by a provider to correct an error made during the desk review or audit, or based on new data not available to the provider prior to the submission of the original cost report.
  • Cost Report Appeals – This is an appeal that may be requested that is related to adjustments made to the final settlement.
  • Detailed PS&R – This is a listing of claims for a set period.
  • Provider Based Determinations – A request to review provider based facilities to ensure they meet Medicare regulations.

NOTE: Please refer to MLN Matters® article MM10611 for more on submitting cost reports.

• You must upload at least one document to be sent with the form. Attachments can be up to 40MBs in size, not to exceed to total of 150MBs for all attachments. The documents must be in a PDF format.
• Click on the “Choose File” button and a window will open allowing you to locate and attach the PDF document to the form. Each attachment will populate in the “Attached Files” window.

  

• Enter the name of the person submitting the form. Click the “Submit” button when the form is complete and ready to be submitted. The date will auto-populate.

  

• An ‘e-signature’ box will appear, asking you to verify that the information entered and attachments are all correct. This ensures the signature requirements have been met.

  

Once received, confirmation will be delivered to your secure Messages inbox letting you know.

Responses sent to you from our A&R team will also be delivered to your Messages inbox.

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Comparative Billing Reports

Comparative Billing Reports (CBRs) are created to give you a snapshot of your specific billing pattern data in comparison to peer groups within your CGS jurisdiction. This information is helpful in conducting education and self-audit activity.

After clicking the "CBR" link for your line of business and the form loads, the Provider Information section will auto-populate.

Select the calendar quarter from the drop-down box.

For Part B CBRs, identify the specific CPT/HCPCS code and enter the performing provider's PTAN. Click the "Validate" button so that myCGS can verify the PTAN entered is associated with the group identified in the "Provider Information" section.

NOTE: There is no additional information for HHH and Part A users to enter.

Click Submit to send your CBR request. An "e-signature" box will appear, asking you to verify that the information entered is correct. This ensures the signature requirements have been met.

Once received, confirmation will be delivered to your secure Messages inbox letting you know. myCGS will notify you when the CBR has been generated.

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Responding to Requests for Additional Documentation

The myCGS web portal allows you to respond to our additional documentation request (ADR) letters directly from your MR Dashboard and Claims tab.

MR Dashboard:
If you have a pending ADR on your MR Dashboard, simply click on the 'Submit Documents' icon, which will connect you directly to the MR ADR Form.

You can also access the form from the 'Detailed Claim Status Information' page by clicking the 'Submit Document' button.

For your convenience, the MR ADR form will auto-populate with information in most of the required fields.

Claims Tab:
When checking the status of your claims from the Claims tab, if you see a claim pending awaiting response to an ADR letter, you can respond by selecting the 'Submit Documents' button located at the bottom of the page.

To save you time, the form will auto-populate with information in most of the required fields.

When claims are pending due to an ADR, do not use the 'Ask a Question' button, as it will not route the documentation you attached to the pending claim.

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Reconsiderations (HHH and Part A)

Home Health, Hospice, and Part A providers may request a Reconsideration (second-level appeal) through myCGS. The request must be submitted within 180 days from the date of receipt of the Redetermination decision. In cases where the Redetermination request is dismissed, a Reconsideration may be requested within 60 days of the dismissal notice.

The form is available under the Claims tab for claims that have completed the 1st level appeal, Redetermination. Refer to the Appeals: Submitting a 2nd Level Appeal section of this manual for step-by-step instructions on how to submit a 2nd level appeal.

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General Inquiries

You may submit general questions through myCGS related to various topics, including appeals, finance, education, and medical review.

NOTE: This form should not be used in place of the other functions available to you through myCGS.

• To submit a Redetermination (1st level appeal) please complete the Redetermination Request Form.
• To submit an eOffset (offset authorization for a demanded overpayment), please complete the eOffset Request Form.
• To respond to an additional documentation request (ADR) from our medical review or claims departments, please complete the MR ADR or Claim ADR Response Form.

After clicking the form link and the page loads, you will find some fields are auto populated based on your myCGS user ID. The required fields that must be completed to submit the General Inquiry Form are identified by a RED asterisk (*).

Complete the top portion of the form.  There is also an area to summarize the reason for the inquiry.  In 2000 characters or less, summarize the issue.

You must include an attachment with your inquiry. Attachments must be in a PDF format and no larger than 40MBs in size. Click the ‘Choose File’ button to locate the PDF document on your system.

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Immediate Offset

An Immediate Offset is your electronic authorization allowing us to offset funds to satisfy an overpayment requested by CGS. You may request an immediate offset each time a demanded overpayment is received or authorize a permanent request for all future demanded overpayments.

The forms are located under the Financial Forms sub-tab. Instructions on completing the forms are available in the Financial Tools section of this user manual.

NOTE: Provider Administrators have access to all tabs within myCGS. Provider Users have access to only the tabs the Provider Administrator has granted them permission to access. If you have access to the forms available in myCGS, the "Forms," "Financial Tools," and "Claims" tabs will be visible once you successfully log into the portal. If a tab is grayed out but you believe you need access to the tab, contact your Provider Administrator.

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Credit Balance

A Medicare Credit Balance is an amount determined to be refundable to the Medicare program for an improper or excess payment made to a provider because of patient billing or claims processing errors. Each HHH and Part A provider must submit a quarterly Credit Balance Report (Form CMS-838). To ensure timely receipt and processing, myCGS is the preferred method of submission.

The form is located under the Financial Forms sub-tab.

1. Select 'CMS 838 Credit Balance' from the "Select a Form" drop down menu. The myCGS Credit Balance form will display.
2. The top of the 'Provider Information' section will auto-populate. Select the quarter end date from the drop-down menu.
   
   
   
   
3. Check one item from the list: "Qualify as a Low Utilization Provider"; "The Credit Balance Report Detail Page(s) is attached"; or "There are no Medicare credit balances to report for this quarter (No Detail Page(s) attached)."
4. In the 'Attachments' section, attach up to 10 documents in a PDF format (each up to 40MB in size, not to exceed a total of 150MBs). NOTE: CMS regulations prevent CGS from accepting electronic signatures; therefore, the first attachment must be the signed CMS-838 Credit Balance form.

See "Submitting a Form" below for next step.

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Overpayment Recovery Request (Part B)

Part B providers may submit an Overpayment Recovery Request to notify us of an overpayment. Doing this will generate a demand letter identifying the amount to be refunded.

Once the request is received, approved, and processed, we will issue an overpayment demand letter. The debtor has 30 days from the date of the demand letter to submit the refund. (See Immediate Offset in the Financial Tools section of this user manual to avoid delays and possible interest added to the principal balance.)

After clicking the form link the Overpayment Recovery Request form will display. Required fields are identified by a RED asterisk (*). For your convenience, some fields of the form are pre-populated with information specific to your myCGS User ID and PTAN/NPI combination.

Verify/complete the PROVIDER INFORMATION section. Add your phone number in the appropriate field. NOTE: Should we need to contact you with questions about your request, please be sure to enter a number to a direct line to reach you.

Complete the BENEFICIARY INFORMATION section by entering the patient's name and Medicare ID.

Complete the CLAIMS INFORMATION section by entering the claim Internal Control Number (ICN). The ICN is located on your CGS Remittance Advice (RA). Also, select the option to identify whether this request is related to Medicare Secondary Payer (MSP) or not related to MSP (NON-MSP).

• MSP: If MSP is involved, click the drop-down box under Type and select the appropriate value. If none apply, select Other and a box will display allowing you to enter text identifying the specific reason for your request. Also, complete the Line and Date of Service fields.
  • Under the Line drop-down, select the applicable claim line number. If this applies to all lines of the claim, scroll to bottom of drop-down and select ALL.
  • Enter the primary payer allowed and paid amounts, and the "Obligated to Accept" amount (if the provider has contracted with the primary insurance company and is obligated to accept their allowed amount for the service). Also, enter the From and To date of service.
  • Click ADD to insert this line onto the form.
  • Once the line is added to the form, you may:
    • Add additional lines from the claim (unless ALL is selected)
    • Delete a line added to the form by selecting the red 'X' in the last column.
    • Complete the request.
      
      
      
      
      
• NON-MSP: If MSP is NOT involved, click the drop-down box under Type of Adjustment to identify if the overpayment applies to a single line of the claim or the entire claim.
  
  
  • If the overpayment applies to the entire claim, under the Type drop-down, select the reason the overpayment occurred. The remaining fields (Action and Line) will auto-populate.
  • If the overpayment applies to a specific line(s) of the claim and not the entire claim, under the Type drop-down, select the reason the overpayment occurred. If none apply, select Other and a box will display allowing you to enter text identifying the specific reason for your request.
  • Select appropriate value under the Action drop-down. Values vary depending on what was selected under the Type drop-down. The option under Action is DENY for all types except:
    • Corrected # of Units: The value is REPLACE.
    • Corrected Date of Service: The value is REPLACE.
    • Corrected Procedure Code: The value is REPLACE.
    • Modifier: The values are ADD, REMOVE, or REPLACE.
  • Under the Line drop-down, select the applicable claim line number. If this applies to all lines of the claim, scroll to bottom of drop-down and select ALL.
  • The Position drop-down displays only when Modifier is selected under the Type field. In this case you would identify the position of the modifier.
  • The New Value field is required when the following are selected under the Type field:
    • Corrected # of Units: Enter the correct number of units.
    • Corrected Date of Service: The field changes to FROM/TO DATE OF SERVICE. Enter the correct date of service.
    • Corrected Procedure Code: Enter the correct procedure code.
    • Modifier: When ADD or REPLACE is selected under Action. Enter the correct modifier.
  • Click ADD to insert this line onto the form.
    
    
    
  • Once the line is added to the form, you may:
    • Add additional lines from the claim (unless ALL is selected)
    • Delete a line added to the form by selecting the red 'X' in the last column.
    • Complete the request.

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Prior Authorization for Certain Hospital OPD Services (Part A)

This option allows users to submit a prior authorization request (PAR) for certain hospital outpatient department (OPD) services. See Hospital Outpatient Department Prior Authorization for details about the prior authorization process.

NOTE: Since prior authorization is a condition of payment for the hospital OPD, this form is only available to users who sign in with a user ID registered to a Part A NPI/PTAN.

Once logged into myCGS, select the FORMS tab.

• Under the "Select a Topic" drop-down box, click "Prior Authorization."
• The "Select a Type" drop-down will default to "PA OPD."
• Select the "PA OPD: PA-J15-A-1000" link at the bottom of the page.
  
  

Once the PA form loads you will find several sections requiring your attention. Carrots at the top corners of each section allow you to collapse or expand the sections.

Facility Information

This section will auto-populate with information specific to your myCGS ID and provider information. No changes can be made to the Provider Information section.

Request Details

Select the appropriate request type.

• Initial Request: First prior authorization request (PAR) submission for this beneficiary/date of service.
  
  

• Resubmission Request: Any subsequent PAR submission (i.e., to correct an error or omission identified after receiving a non-affirmation decision).
  • Include additional/updated documentation not provided with a prior PAR.
  • Enter the 14-digit unique tracking number (UTN) assigned to the most recent PAR. (Select 'Get Previous Submission Information' to verify).
    
    
  
  
• Expedited Request: Used ONLY when a delay for a decision could seriously jeopardize the beneficiary's life, health or ability to regain maximum function. Enter the specific reason/rationale for CGS to substantiate the need for an expedited decision.
  
  

Requestor Information

This section identifies your name, email, and phone number associated with your myCGS user ID and will auto-populate. If you would like to receive your PAR decision via fax, check the box and enter the fax number of the hospital OPD.

Beneficiary Information

Enter the beneficiary's Medicare ID, first name, last name, and date of birth.

For initial requests, select "Validate Beneficiary". myCGS will verify the information you entered corresponds with the beneficiary’s eligibility record on file.

NOTE: Refer to the beneficiary's Medicare card to verify this information before you submit a request.

Attending Physician Information

Enter the name, National Provider Identifier (NPI), and complete address of the physician/non-physician practitioner (NPP) who has overall responsibility for the patient's medical care and treatment. If the attending physician would like to receive a copy of the PA decision letter, enter the physician's fax number to the form.

Services Requested

The "Services Requested" section of the form varies depending upon the type of service for the PAR.

• On the "Select a Service" drop-down, click on the service for which the PAR is for. Depending on the service selected, certain fields will display.
  • HCPCS Code: Select the CPT code from the listing
  • Primary Diagnosis Code: Enter the primary diagnosis code
  • Number of Units: Enter the number of units (for Botulinum Toxin Injection PARs)
  • Secondary Diagnosis Code: Identify a second diagnosis code, if applicable
  • Related Codes: Enter any CPT/HCPCS codes related to those selected above
  • Dates of Service: Enter the date the service will be rendered
  • Type of Bill: Identify the appropriate TOB applicable to this service
    • Part A hospital outpatient (TOB 13X)

• Service Related Questions will display based upon the type of service. Answers to these questions help support medical necessity.
  
  

Attachments

Documentation from the medical record to support medical necessity of the service is to be attached to the myCGS form. Attachments must be in a PDF format and no large than 40MBs. The total of all attachments cannot exceed 150MBs.

NOTE: You must attach at least one document. Please refer to the applicable Local Coverage Determination and/or Local Coverage Article for direction.

Once the form is complete and all documentation attached, select "Submit" to send the PAR to CGS.

An eSignature box will display. Click OK to confirm the request and to sign the form.

NOTE: If you do not click OK to sign the form, it will not be sent.

Confirmation

Confirmation messages will be delivered to your Messages inbox. The message that includes a Submission ID may be used to check the status of the PAR by entering the Submission ID into the "Get Status" screen located on any tab throughout the portal.

• PAR statuses available:
  • Confirmed: CGS received the request.
  • Decision: CGS issued an affirmed or non-affirmed decision. Refer to the PAR Decision Letter for details.
    
    

View PAR Decision Letter

The decision letters for PARs submitted through myCGS will be delivered to your myCGS Messages inbox (unless you request to receive it via Fax in the Requestor Information section above.) You may also check the Prior Authfolder for decision letters.

The decision letter will open as a PDF document.

NOTE: PAR decisions and UTNs are valid for 120 days (the decision date is counted as day 1).

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Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services (Part A) Exemption Opt Out

Hospital Outpatient Department's (OPD) who demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization are eligible for exemption. This exemption would remain in effect until CMS elects to withdraw the exemption. To be eligible, OPDs need to submit at least 10 prior authorization requests during the previous review period and achieve a provisional affirmation threshold of at least 90% during an annual assessment.

Hospital OPDs have the option to opt out of the exemption process and continue submitting PARs. Hospital OPDs that choose to opt out of this exemption process must submit an opt-out request. To complete the myCGS form:

Once the form loads, you will find some information pre-populated with identifying information for your PTAN/NPI and myCGS account.

Complete the form by entering the contact person's name, title, phone number, and email address. If you would like to receive our decision letter via fax, check the box and enter the fax number.

Read the certification statement. To agree, click the check box. Click submit to send the completed form.

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Prior Authorization for Repetitive, Scheduled, Non-Emergent Ambulance Transports (RSNAT)

This option allows you to submit a prior authorization request for RSNAT. See the Prior Authorization for RSNAT webpage for details about the prior authorization process.

• Log in with a user ID registered to a Part B NPI/PTAN.
• Select the ‘Forms’ tab.
• Choose ’Prior Authorization’ from the ‘Select a Topic’ drop-down selection.
• The ’Select a Type’ drop-down selection will default to ’PA Ambulance’.
• Select ’PA Ambulance: PAA-J15-B-1000’ at the bottom of the page.
  
  
  

Request Details

Select the appropriate request type:

• Initial Request: First prior authorization request (PAR) submission.
• Resubmission Request: Any subsequent PAR submission (i.e., to correct an error or omission identified after receiving a non-affirmation decision).
  • o Enter the 14-digit Unique Tracking Number (UTN) assigned to the most recent PAR. (Select ’Get Previous Submission Information’ to verify).
    
    

Select the appropriate HCPCS code(s) (A0428 or A0426) and enter the applicable origin/destination modifiers, start date, and number of transports.

Ambulance Supplier Information

This section auto-populates based on your user ID. Exception: Select the state where your vehicle is garaged.

Beneficiary Information

Enter the beneficiary's Medicare Beneficiary Identifier (MBI), name, and date of birth.

NOTE: See the ‘Eligibility’ tab to verify and ensure the information  you enter matches.

Certifying Physician Information

Enter the certifying physician/non-physician practitioner's name, identifiers (NPI/PTAN), and complete address.

Requestor Information

This section auto-populates based on your user ID. To receive the PAR decision via fax, check ’Send decision by fax’ and enter the fax number.

Questions

Answer each service-related question to help support medical necessity and enter comments as appropriate.

Attachments

Select the 'Choose File' button to attach ALL supporting documentation. Attachments must be in PDF format and no larger than 40 MB each. The total for all attachments can’t exceed 150 MB.

If you’re ready to send the request, click ‘Submit’.

The eSignature box will display. Before you select ‘OK’ (to sign and acknowledge that you’re authorized to submit the information), verify that the displayed information and attachment(s) are correct.

If you need additional time, click ‘Save’.

A confirmation message will display.

To access a saved form, go to your ‘Messages’ tab and select ‘Saved Forms’. Select the form you want to load and update.

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Attachments Section

Most of the forms in myCGS give you the option to attach additional documentation (e.g., medical records, operative/radiology reports, attestations) you would like CGS to consider when processing your request.  You may attach up to 10 documents.  Each document must be in a PDF format and can be up to 40MB each. The total size of all attachments cannot exceed 150MB in size.

To add an attachment, select the “Choose File” button, and a window will open allowing you to locate the PDF document you wish to add.  Select the PDF document to attach it.  Repeat this process for each additional PDF document you wish to attach.

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Submitting a Form

Once all required information has been entered, and all necessary PDF documents have been attached, click "Submit."

An e-signature box will appear, asking you to verify that the information entered and documents attached are correct. This ensures the signature requirement for all forms have been met.

If the information was entered correctly, and all desired attachments were included, click "OK" to submit the form and all attachments.

If any information needs to be corrected, or if any attachments need to be added or deleted, click "Cancel" to return to the form.

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