LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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Written Inquiries Data

For provider inquiry analysis, CGS maintains a systematic and reproducible provider inquiry analysis program for written inquiries. We review the top reasons you write to us and use that information to develop and implement resources to address the needs of our providers.

Before you write to us, please be sure you are sending correspondence to the correct department and address. Check here to avoid misrouted written inquiries by selecting the "Mailing Addresses" icon.

One way to avoid misrouted written correspondence is to send your inquiries to us electronically through myCGS! If you have general questions regarding appeals, claims processing, finance, medical review, provider enrollment, or provider outreach, we encourage you to send them via myCGS. Check here for a job aid to help you navigate this myCGS function.

For your convenience, we also offer a comprehensive list of Frequently Asked Questions (FAQs). To save yourself some time, check the FAQs first!

Below is a list of the top reasons providers write to us.

Top Written Inquiries: October 2020

Reason Resource/Reference

Appeals: Duplicate

The Interactive Voice Response (IVR)PDF is a resource available to you to check the status of Redeterminations.

Check the Appeals webpage for resources:

  • Appeals Timeliness Calculator
  • Help determining what form the use
  • Link to Redeterminations form

NOTE: Be sure to include authentication elements with your appeal requests! This includes:

  • Your National Provider Identifier (NPI);
  • Your Provider Transaction Access Number (PTAN);
    • Be sure to use the Group PTAN (when applicable). Individual PTANs are not used in the privacy verification process when a Group PTAN is assigned to the provider.
  • The last 5-digits of your tax identification number (TIN).

General Information: Incomplete Information Provided

When submitting inquiries, it is important that you include information needed to authenticate yourself, as this is a requirement of the Centers for Medicare & Medicaid Services (CMS). The data elements required to do this include:

  • Your National Provider Identifier (NPI);
  • Your Provider Transaction Access Number (PTAN);
    • Be sure to use the Group PTAN (when applicable). Individual PTANs are not used in the privacy verification process when a Group PTAN is assigned to the provider.
  • The last 5-digits of your tax identification number (TIN).

If your inquiry is specific to a Medicare patient, the following beneficiary information also needs to be authenticated:

  • The patient's Medicare ID
    • Either the Medicare Beneficiary Identifier (MBI) or the Health Insurance Claim Number (HICN)
  • First initial
  • Last name (first 6 letters); and
  • Date of birth

We cannot process inquiries submitted without these data elements.

Financial Information: Electronic Funds Transfer (EFT)

Existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time of enrollment, enrollment change request, or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT).

Section 1104 of the Affordable Care Act further expands Section 1862(a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means.

An Electronic Funds Transfer Authorization Agreement formExternal PDF must be included with your application request. Your application will be delayed if you fail to include a completed EFT Agreement with your original submission.

To avoid delays with processing your enrollment applications, a voided check or bank letter MUST be submitted with the CMS-588 Electronic Funds Transfer Agreement to confirm your bank account information.

Provider Enrollment: Not Classified

When submitting inquiries, it is important that you include information needed to authenticate yourself, as this is a requirement of the Centers for Medicare & Medicaid Services (CMS). The data elements required to do this include:

  • Your National Provider Identifier (NPI);
  • Your Provider Transaction Access Number (PTAN);
    • Be sure to use the Group PTAN (when applicable). Individual PTANs are not used in the privacy verification process when a Group PTAN is assigned to the provider.
  • The last 5-digits of your tax identification number (TIN).

Everything regarding credentialing is available to you on Provider Enrollment webpage!

  • Use the Provider Enrollment Interactive Help Tool for guidance on which CMS-855 enrollment application to complete and what additional documentation to include
  • Only delegated and authorized officials may receive a status of a provider enrollment application
    • Please be sure to identify anyone who is privy to this information on your application
    • THE best way to check the status of an application is to use the Provider Enrollment Application Status Check Tool!
      • Must have the CGS Reference Number from your acknowledgement letter, NPI, PTAN or Web Tracking ID from your PECOS on-line submission
  • Also, check out the most common provider enrollment application issues we see with those submitted via Internet-based PECOS and on the paper CMS-855

Claim Denials: Medicare Secondary Payer (MSP)

When Medicare is secondary, the primary payer must be billed first.

  • Check this article for steps to help you with MSP claims.
  • Refer to the MSP Job AidPDFto determine how a patient’s record “should” appear.
    • If the patient’s record is different than what the flowchart suggests, please contact the Benefits Coordination and Recovery Center (BCRC).
  • Verify patient eligibility to determine whether there is a payer primary to Medicare.
  • The Interactive Voice Response (IVR)PDF is also a resource.

Need help determining the claim payment calculations?  Check out the Medicare Secondary Payer Tool!

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