myCGS User Manual
Contents
1. The status of your request is displayed below r eue_rse uwT wawws SF Submission ID Se oo oo Submission ID Status IN PROCESS Date O1 15 2014 13 37 07 Option Selected Stop Provider Level Offset Previously Requested Provider Name E a PTAN E Once your e Offset request is processed and completed you will receive another message with the Subject Secure Form Completed in your message inbox myCGS User Manual Page 19 Forms Tab for Part B Providers CHAPTER 7 ccs Home Claims Remittance Eligibility Financial Tools Messages Forms Support Admin My Ac User Angels Doe Provider Frederick Medical Center PSC Logout EE You have S unread message s and O alerts Go To page SeectFom The status of your request is displayed below Submission ID i Fa SE Submiesion ID Statue COMPLETED LL TL Submitting Reopening Requests The Forms tab option within myCGS also allows users to submit electronic Reopening requests Providers may request Reopenings to correct minor errors or omissions to a previously processed claim without using the formal appeals process Users may also monitor the status of their requests using this option ACCESSING THE myCGS REOPENING FORM Once you access the Forms tab in the Go To Page field click the drop down box and select Reopenings You can also access the Reopening form from the Go To Page field located und2. Forms Tab for Part B Providers CHAPTER 7 Supporting Documentation Please attach all documentation up to 5 MB each that you would like included in reopenings request Examples of supporting documentation would include Attachment 1 Users Public Documents eCopy Sar Browse Attachment 2 Attachment 3 Attachment 4 Attachm 5 Name te 08 01 2014 Required Meld Below the Attachments section is the Name field The first and last name of the person completing the form must be entered into this field MULTIPLE BENEFICIARY REOPENING FORM There are three sections to the form 1 Provider Information 2 Claims Information and 3 Supporting Documentation Each field marked with a RED asterisk is a required field Provider Information Section You must complete the following fields e Provider Address 1 e Provider Phone Number Provider City Last 5 Digits of Tax ID e Provider State e National Provider Identifier NPI Provider Zip Code Some fields will be pre populated based on your myCGS account Provider Information Provider Name Provider Name Here Last 5 Digits of Tax ID OOO Provider Number NNNNNNNNNN HPI NNNNNNNNNN Provider Address 1 123 Street Name Provider Address 2 Provider City City Mame Provider State sT Provider Zip Code 12345 Provider Phone Number DOK HOOK OO Reason for Request Enter the reason rationale for the reopening request in 1200 c
3. CHAPTER 7 myCGS User Manual Forms Tab for Part B Providers 6 C G S Originated July 31 2012 Revised September 29 2015 A CELERIAN GROUP COMPANY 2015 Copyright CGS Administrators LLC CENTERS FOR MEDICARE amp MEDICAID SERVICES Forms Tab for Part B Providers CHAPTER 7 Table of Contents Formos Tab iii ccccccccccccccccceecceeeeceeeseseesssevsseessssevsesenssevsseestsseeneseens 4 Submitting a Redetermination Request 20000200 eerren a Accessing the myCGS Redetermination Form 4 Determining Timely Appeal Request l enn 5 Completing the myCGS Redetermination Form 6 Beneficiary Information Section rreren 6 Provider Information Section rren 6 Claim Information Section 0000000 cceeccceceescceceeseeeeneeeeeeneseeens 7 Attachments Section ooo ooo eccecccecceesececeveseeeeeesseeeeenerseesens 8 Submitting a Redetermination Request Form 9 Redetermination Submission Message and Appeal DCN 9 Checking the Status of a Redetermination Request ooo ooceececceeeee 10 Viewing Redetermination Documents 11 Submitting an e Offset Request ooo ooo i cccccceeceeeesececeeeeteseeeeeerentseeeesens 12 Accessing the myCGS e Offset Form 12 Completing the Immediate Offset Form e Offset 0 ceeeeen 13 Provider Level Offset l teaebadeacganr anda wiawes 14 Demand Letter Offset 00000 ooo coool ccccccccccccccceecevecevttersseeeeeeceeeveeenees 15 Lett
4. Select date from the calendar icon e Service Date To Select date from the calendar icon e Claim ICN This is the internal control number ICN of the original claim The ICN can be located on your remittance advice If you are unable to locate the ICN you may enter 13 Os zeroes to bypass the field e HCPCS Enter the applicable CPT HCPCS code Click Add Remove or Clear All to add remove or delete the code entered myCGS User Manual Page 22 CHAPTER 7 Forms Tab for Part B Providers Reason for Request Enter the reason rationale for the reopening request in 1200 characters or less Hover your cursor over the Examples of request reasons include link for assistance If the reopening request is for multiple dates of service please enter all dates and applicable CPT HCPCS codes in addition to the specific correction being requested Claims Information Service Date From Ovo 14 x Service Date To O5 01 2014 Claim ICN NNN HCPCs Reason for Request The reason T 99213 should be changed to CPT code for request must be the same reason F3 for all claims listed Be specific in your request If you have multiple DOS or lines that need to be reopened on the claim please indicate the specific line numbers in the comment section Examples of request reasons include 1150 characters left CPT only copyright 2014 American Medical Association All rights reserved CPT is a registered trad
5. procedure code and details of the change requested Documents attached must be in a PDF format and up to 5MB in size To add an attachment select the Browse button and a window will open allowing you to locate the document you wish to add Select the document to attach it Repeat this process for each additional document you wish to attach Click the RED X to remove an attachment Please attach a remittance or a spreadsheet listing the claims in pdf format only up to SMB The remittance must be clearly marked with claim number and the requested correction The spreadsheet must include claim number date of service procedure code and detailed instructions of change Claim Attachment T Supporting Documentation Section This section of the Reopening form allows you to attach documentation e g medical records operative radiology reports you would like CGS to consider when processing your reopening You can attach up to 4 documents up to 5 MB each The documents must be in a PDF format To add an attachment select the Browse button and a window will open allowing you to locate the document you wish to add Select the document to attach it Repeat this process for each additional document you wish to attach Click the RED X to remove an attachment Supporting Documentation Please attach all documentation up to 5 MB each that you would like included in reopenings request Examples of supportin
6. Overpayment Letter and Overpaid Amount field with auto populate Provider NPI Requestor Name Requestor Phone Number See ePeeeeTeeTEeseeTeeTVTEeVTEseeTEes ws E AR Number 7234560001224567AA Bf cate of overpayment Letter pasos Ib Overpaid Amount Once all fields are completed click the Add AR Details button All information will be added to the form Enter additional ARs if submitting a request for more than one AR under the PTAN NPI Up to 10 ARs may be entered on the same form If at any time the information is entered incorrectly click the Reset AR Details button and re enter the information After entering all ARs click the Submit button myCGS User Manual Page 16 Originated July 31 2012 Revised September 29 2015 2015 Copyright CGS Administrators LLC Forms Tab for Part B Providers CHAPTER 7 01 23 2014 Submit Ee After clicking the SUBMIT button to submit the form an e signature box will appear asking you to verify that the information entered is correct This ensures the signature requirement for all requests have been met Click OK if you agree or Cancel to return to the form to make corrections Signature i this information correct Please review your information carefully if it is correct please press Ok to submit If not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the informati
7. Provider Information 3 Claims Information and 4 Attachments Each field marked with a red asterisk is a required field Beneficiary Information Section You must complete the following Beneficiary Information fields to submit your redetermination request using myCGS e Patient Name e Medicare Number e State e Phone Number Get Status You have 2 unread message s and O alerts _ CEE Goto page SelectForm Redetermination 1 Level Appeal J15 Part B Beneficiary Information Patient Name Medicare Number State Phone Number l Provider Information Section The Contract Region Provider Name Provider Number PTAN and National Provider Identifier NPI fields default based on your User ID You must complete the following fields e Provider Address 1 e Provider Address 2 optional field myCGS User Manual Page 6 CHAPTER 7 Forms Tab for Part B Providers Provider City e Provider State Provider Zip Code e Provider Phone Number e Tax ID Provider Information Contract Regen Part B Kentucky Provider Name COS SUPERADMIN Pronder Number PTAN 7777777 National Provider Identifier MPT re ee Provider Address 1 Provider Address 2 Provider City Provider State hd Provider zip Code Provider Phone Number od To Claim Information Section e Service Date From e Service Date To Date of Initial Determination This is the dat
8. Service 2 2 2015 Date Of Letter 2 5 2015 ADR Letter Number 123 CPT Code s 99213 Is this a group PTAN Y What is the performing provider PTAN Attached Files HealthInsuranceForm pdf Signature Information CHECKING THE STATUS OF AN MR ADR RESPONSE To check the status of the actual claim for which the ADR was sent go to the Claims tab For details on checking the status of claims go to Chapter 2 Claims Tab http www cgsmedicare com pdf mycgs chapter2 pdf in the myCGS User Manual Home Clsims Remittance Eligibility Financial Tools Support Admin My Account Inquiry myCGS User Manual Page 36
9. field click the drop down box and select Secure Forms Home Claims Remittance Eligibdity Financial Toos Messages Forms User Provider You have unread message s and O alerts Secure Forms Once on the Secure Forms page you will find options to Select a Topic and Select a Type The Select a Topic field will default to Appeals as this is currently the only option available Likewise the Select a Type field will default to First level appeal on a Medicare Claim myCGS User Manual Page 4 Forms Tab for Part B Providers CHAPTER 7 Welcome to secure forms You can now submit forms to CGS Administrators securely through myCGS You may attach up to five POF attachments to each form Each attachment can be up to SMB in size The forms and attachments are automaticaly entered inte our workflow This makes form processing more efficent and cost effective To begin please select an answer to the questions from the drop down selections below Based upon the answer given for each of the questions the avaiable or will appear at the bottom of this box At this time only Appeals forms are available ee ee ms a Select a Topic Appeals Select a Type First evel appeal n a Medicare Claim 2S SS eo 2 To verify you are within timely filing requirements for this Appeal please use our Appeals Calculator Is your appeal late over 120 days for a redetermination or over 36
10. one or multiple claims for one beneficiary when Medicare Secondary Payer MSP is involved SINGLE BENEFICIARY REOPENING FORM There are four sections to the form 1 Provider Information 2 Beneficiary Information 3 Claims Information and 4 Supporting Documentation Each field marked with a RED asterisk is a required field Provider Information Section You must complete the following fields e Provider Address 1 e Provider Phone Number Provider City Last 5 Digits of Tax ID e Provider State e National Provider Identifier NPI Provider Zip Code Some fields will be pre populated based on your myCGS account Provider Information Provider Name Provider Name Here Last 5 Digits of Tax ID SKYY Provider Number NNNNNNNNNN NPI NNNNNNNNNN Provider Address 1 123 Street Name Provider Address 2 Provider City City Mame Provider State ST Provider Zip Code 12345 Provider Phone Number 900K OOSK Oe Beneficiary Information Section You must complete the following fields Beneficiary Name Beneficiary City State and Zip Code Beneficiary Medicare Number Beneficiary Phone Number Beneficiary Address Beneficiary Information Beneficiary Name Name Here Medicare Number NAINA Ss Beneficiary Address 1 7 123 Street Name Beneficiary Address 2 Beneficiary City City Name Beneficiary State eis Tet Y i apap e 12345 Benefit Y F ONG Claim Information Section e Service Date From
11. 5 days for a reopening No Redetenmination 1 Level Appeal EA 15 8 1000 Determining Timely Appeal Request Redetermintation requests must be submitted within 120 days of the initial determination i e date on the Medicare remittance advice myCGS will ask Is your appeal late and you must select yes or no from the drop down box Sebect a Type First bevel appeal on a Medicare Chim To verify you are within timely filing requirements for this Appeal please use our Appeals Is your appeal late over 120 days for a redetermination or over 365 days for a reopening No Redetennination 1 Level Appeal EA J15 8 1000 If you are unsure whether your redetermination request is timely myCGS offers a link to a CGS Appeals Time Limit Calculator to assist you To access the Calculator click on the Appeals Calculator link located in the lower right of the screen Select a Types First level appeal on a Medicare Claim To verify you are within timely filing requirements for this Appeal please use our Appeals Calculator Is your appeal late over 130 days for a redetermination or over 365 days for a reopening No Redetennination 1 Level Appeal EA 315 8 1000 The Appeals Time Limit Calculator will open in a new window Enter the date of the initial determination for the service being appealed and click Calculate Appeals Time Limit Calculator I would like to submit my Redete
12. 90 11 10 EST 2015 can Mon Feb 9 18 38 EST 2005 Selecting the second message with the Submission ID assigned to the form provides instructions on how to view the status of your request Once the message is open click on the Submission ID in the message or select the Get Status button located in the upper left of the screen and entering the Submission ID Message x Subject Secure Form Confirmation Message Your MR AQB pesppasebas heeg received by CGS The Submission ID assigned to your MR ADR Response NERDE u T check the status of your request sign into myCGS and select the Message Inbox tab on Get Status button Enter the Submission ID assigned to your MR ADR request in the Submission ID box Thank you for using myCGS CGS Administrators LLC Okw5715 The details of the MR ADR Response form submitted will display It will show a CONFIRMED status confirming the MR ADR Response form was accepted myCGS User Manual Page 35 Forms Tab for Part B Providers CHAPTER 7 You have 2 unread message s and 0 alerts J co To page The status of your request is displayed below Submission ID W151021504300023 Submission ID Status CONFIRMED EF Oe eee ee ee Se ae Submitted Request Summary Provider Information Provider Name Part B Kentucky National Provider Identifier NPI Provider Number PTAN XXXX Patient amp Claims Information HIC Number 123456a ICN 1234567890123 Date Of
13. DF format To add an attachment select the Browse button and a window will open allowing you to locate the document you wish to add Select the document to attach it Repeat this process for each additional document you wish to attach Click the RED X to remove an attachment Supporting Documentation Please attach all documentation up to 5 MB each that you would like included in reopenings request Examples of supporting documentation would include Attachment 1 Attachment Attachment 3 Below the Attachments section is the Name field The first and last name of the person completing the form must be entered into this field SUBMITTING THE REOPENING REQUEST FORM Once all requested information has been entered and all necessary documents have been attached click on the Submit button Name jate oB 01 2014 Required Field _ ER J15 B 1000 An e signature box will appear asking you to verify that the information entered and attachments are correct This ensures the signature requirement for all reopening requests has been met Sipnature is this information correct Pease review your information and attachments carefully If they are correct please press Ok to submit if not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the information p Ok Cancel If the information was entered correctly and all de
14. Select a Topic and Select a Form The Select a Topic field will default to Financial as this is currently the only option available Under the Select a Form drop down click on the eOffset option to load the form Financial Forms Welcome to the mplGs Financia Fores submission pape To begin please choose your form type Based on pour selection the awadetie form will appear at the bottom of this bow Complete the form and add attachments a4 mtceasary and select qb The form and al attachments ral be automatcaly ateei ito cur sobd management astem You will rece CAIETE of your fon HTE i yo Hesg Enea urh Chet Hessa Cab Thank vou for making Torn pretas Thee ecb ane Olde eect Select a Topic Financial w Completing the Immediate Offset Form e Offset Once you select the form the myCGS eOffset page will appear This page explains the immediate offset process and provides critical timeframes that must be considered prior to submitting a request myCGS User Manual Page 12 Forms Tab CHAPTER C for Part B Providers You have B unread message s and O alerts raip Go To page SelectFom e Offset Begnning July 1 2012 a new standard immediate offset process is impemented for al Part A providers and all Part B physiaan and other supphers This new process allows you to request an mwmediate offset each time you receve a demanded overpayment or you can make a permanent request for al future deman
15. _Connection_ 15_Winter2013 pdf Dove Data Credit Memos LOK pdf PC ACE Pros Webwork Installation Instructors pdf Once review of your appeal request has been completed and a determination has been made by CGS s Appeals Department you will receive another message with the Subject Secure Form Completed myCGS User Manual Page 11 Forms Tab for Part B Providers CHAPTER 7 SUBMITTING AN E OFFSET REQUEST The Forms tab option within myCGS also allows Users to submit an electronic authorization to offset from a pending overpayment due to CGS using an electronic eOffset Request Form Providers may request an immediate offset each time a demanded overpayment is received or authorize a permanent request for all future demanded overpayments Users may also monitor the status of their requests using this option Accessing the myCGS e Offset Form Once you access the Forms tab in the Go To page field click the drop down box and select Financial Forms Go To Page Too hiwe Dunread mewisgela and O alert co ai i L Fikirini Part a Ferbeminging Part Bi Secure Forms Welteme to abcure Teena You cae now pubes fern to COS Adminis eters scuil ap ane part A HHH farted te tect fen aad we connie HA Gee Pe Pe Check back often HA ADA Part B You can also access the e Offset form by selecting the Financial Tools tab and then the Financial Forms sub tab Here you will find the options
16. alth Insurance ity KY 12345 6789 XXXXXXXXXA pi a E ai 3 Claim HIC Number en E Ficiary DOCUMENT 1234567390abcdefghij DEAR DOCTOR OR SUPPLIER WE ARE PROCESSING A CLAIM FOR BEN EFICIARY_ RECEIVED ON 02 03 2015 AND WE CANNOT COMPLETE THIS PROCESSING WITHOUT THE INFORMATION REQUESTED BELOW PLEASE ANSWER EACH QUESTION AND RETURN THIS LETTER WITHIN 30 DAYS WE APPRECIATE YOUR ASSISTANCE PLEASE RETURN THIS LETTER WITH THE REQUESTED INFORMATION IF THE REQUESTED INFORMATION HAS NOT BEEN RECEIVED WITHIN 45 DAYS PROCESSING OF THE CLAIM WILL BE DECIDED BY THE INFORMATION PRESENT PAYMENT MAY BE REDUCED OR DENIED IF THIS INFORMATION HAS NOT BEEN RECEIVED ADR Letter Number PLEASE SUBMIT PREOPERATIVE EXAM WITH PATHOLOGY REPORTS AND S01 111123 OPERATIVE NOTE S TO SUPPORT THE MOHS SURGERY PERFORMED m a l e ON 102 02 15 1 INCLUDE A COPY OF ADVANCED Three digit number BENEFLIARY NOTICE ABN OF NON COVERAGE TO THE BENEFICIARY WHERE ICABLE PL W SIGNATURE REQUIREMENTS NECESSARY FOR SUBMISSION OF CL 5 FOR MORE INFORMATION REGARDING SIGNATURE REQUI NTS PLEASE VISIT HTTP WWW CMS GOV REGULATIONS AND GUID MANUALS DOWNLOADS PIMBSCOS PDF ar aman e Date of Service ADDRES D HAND ORNER O 7 np RS PAGE OF THIS LETTER IMAGED MEDICAL DOCUMENTATION FILES ON CD DVD MAY BE MAILED BY ANY MEANS Once you select the link from the landing page the myCGS MR ADR Response form will load There are four
17. appear allowing you to submit your request based on either the offset letter you received from CGS or up to 10 Accounts Receivable AR numbers identified on an attachment to the demand letter Letter Option Selecting the Letter option allows you to enter the number identified in the upper right of the demand letter to request the immediate offset myCGS User Manual Page 14 Forms Tab for Part B Providers CHAPTER 7 MEDICARE CENTERS FOR MEDICARE amp MEDICAID SERVICES _ Letter Number 12345673 Once the form for this option displays you will find the Contract Region Provider Name Provider Number PTAN and Provider NPI fields will show pre populated and identify the User s information You must complete the following fields to submit your eOffset request using myCGS e Requestor Name e Requestor Phone Number Letter Number Name Provider Number PTAN Prowder NPI Requestor Name Requestor Phone Number Letter Humber Date of Overpayment Letter O1f22 2014 After completing all required fields click Submit to submit the form An e signature box will appear asking you to verify that the information entered is correct This ensures the signature requirement for all requests have been met Click OK if you agree or Cancel to return to the form to make corrections eignature b this information correct Please review your information carefully If it is correct please pr
18. d on and after the date this request is processed Debts currently in an offset status wil remain so unti the debt has been satisfied Stop Provider Level Offset Contract Region Provider Name Provider Number PTAH e ee Requestor Phone Number eEE Name Se ee oe ee Required Field After clicking the SUBMIT button to submit the form an e signature box will appear asking you to verify that the information entered is correct This ensures the signature requirement for all requests have been met Click OK if you agree or Cancel to return to the form to make corrections Signature b this information correct Please review your information carefully If it is correct please press Ok to submit If not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the information After submitting the form you will be taken to the Message tab Shortly after submission you will receive a confirmation message confirming receipt of the eOffset request A separate message will be sent to your inbox which will include a Submission ID assigned to your request See Messages in Chapter 6 for more details Checking the Status of an e Offset Request The message with the Submission ID assigned to the eOffset provides instructions on how to view the status of your request You can check the status from this screen by selecting the Submission ID in the message The s
19. ded overpayments Immediate offsets are considered voluntary payments therefore waiving nights to section 935 interest for eigble debts Please remember offset can only take place F payment is stl being received under this payee number You can elect the immediate offset process to avoid making a payment by check and or avoid the assessment of interest if the immediate offset satishes the overpayment in full before aging 31 days from initial demand Please note An immediate offset request will be processed as soon as posable however this request does not guarantee that interest wil mot accrue on the overpayment To elminate the msk of interest accming your request should be submitted as soon as possible after bang notified of the debt as interest automatically accrues 31 days from the date of the initial demand letter There are three different forms available e Provider Level Offset This option is selected to establish immediate offsets for any current and future overpayments e Demand Letter Offset This option is selected if you have received a demand letter from CGS requesting an overpayment be returned e Stop Provider Level Previously Requested Select this option to cancel a request C Provider Level Offset Offset the current overpayment and all future overpayments This option is for the PTAN NPI combination for this ID The selection of this option means offset wil continue even you choose to appeal the debt C Demand Letter O
20. ders CHAPTER 7 Responding to Medical Review Additional Documentation Requests The Forms tab within myCGS includes an option to allow users to submit documentation in response to additional documentation requests ADRs received from our medical review MR department This option is offered as a convenience to you to facilitate an accurate and timely response to our requests Responses to MR ADRs must be received within 30 days of the date on the letter Effective April 1 2015 this timeframe will change to 45 days per MM8583 http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8583 pdf ACCESSING THE MR ADR RESPONSE FORM Once you access the Forms tab in the Go To Page field click the drop down box and select MR ADR You can also access the form from the Go To Page field located under the Claims and Messages tabs ccs Claims Remittance Eligibility Financial Tools Messages Forms Support Admin My ss User User Provider CGS SUPERADMIN Get Stabs Redeterminstons Part A Redetermninatons Part B Secure Forms a HHH Rieopenings Welcome to secure forms You can now submit forms to CGS Administrators securely thin ADR Part A amp HHH select from and we continually add new forms Please check back often for new forms JMR ADR Part B Page field above Once you are on the MR ADR landing
21. e Form Confirmation Your Appeals Redeterminations request has been received by CGS The Submission ID assigned to your appeal request is 13150073000006 To check the status of your request select the Message Inbox tab Click on the Get Status button Enter the Submission ID assigned to your appeal request in the Submission ID box Thank you for using myCG Message From CGS Administrators LLC A page will appear with the information entered on the redetermination form including the beneficiary information the provider information and the claim information The status will appear in the Submission ID Status field The names of the files that were attached with the redetermination form will appear under the Attached Files header however the attachments themselves cannot be viewed from myCGS The status of your request is deplayed below Submission ID W15004 1323200002 aSE ue s 375 Submisseon ID Status IN PROCES k me 3232 2 oo oe Beneficiary Information Patent Name Medicare Number 12345678904 Provider Information National Provider Identifier NPT Provider Number PTAN Provider Phone Number Provider Address 1 Provider Address 2 Prowider City Provider State Provider Zp Code Claims Information t Service Date Clam DCN Froth 12445476745678 0S 2017 DOS 2013 08 01 2013 l e a SF Attached Files semite Date To Imtal Detenmninatton Date Demed Seances EDI
22. e on your remittance advice for the denied claim e Claim ICN This is the internal control number ICN of the original claim you are appealing The ICN is available from your remittance advice Denied CPT HCPCS amp Modifiers Enter the denied CPT HCPCS codes amp modifiers that you are appealing Click Add Remove or Clear All to add remove or delete the code entered e Add Claims Information Once all CPT HCPCS and modifiers are added click the Add Claims Information button Is there an Overpayment Appeal e Reasons Rationale Enter the reason rationale for the appeal Claims Information Service Date From IE x Service Date To Date of Initial Determination E x Claim ICN Denied CPT HCPCS amp Modifiers Chea All Add Claims information Once all information is entered click Validate myCGS will validate the information entered for completeness and accuracy If information is missing or invalid you will receive a message indicating the information that must be corrected If the information was complete and correct you will see this message Your entries have been validated Please attach the required documents input your name and click Submit myCGS User Manual Page 7 Forms Tab for Part B Providers CHAPTER 7 You have 2 unread message s and O alerts Go To page zamri Fan Your entries have been validated Please attach the requir
23. ed documents input your name and click Submit Redetermination 1 Level Appeal J15 Part B Beneficiary Information Attachments Section The Attachments section of the Redetermination form allows you to attach documentation e g medical records operative radiology reports you would like CGS to consider when processing your redetermination request You can attach up to five documents 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 To add an attachment select the Browse button and a window will open allowing you to locate the document you wish to add Select the document to attach it Repeat this process for each additional document you wish to attach Note At least one attachment is required to submit the Form Attachments Please attach all documentation that you would like included in this redetermination You should also include any documentation to support your redetermination request Examples of supporting documentation would include NOTE You may attach up to 5 documents Each attachment must be a PDF and can be up to 40 MB in size The total size of all attachments cannot exceed 150 MB Attachments Browne Below the Attachments section is the Name field The name of the person completing the form must be entered into this field 08 23 2013 Required Freld 4 115 8 1000 Subri Clear S
24. eecceeceeeceeesseeeeeseeeenees 29 Provider Information Section erroreren rrn 25 Claim Information Section rrenen renn 26 Supporting Documentation Section rererere 26 Medicare Secondary Payer Reopening Form 21 Provider Information Section eerren renerrien zy Beneficiary Information Section eerren rreren 27 Claim Information Section erreren errno 28 Supporting Documentation Section 29 Submitting the Reopening Request Form erreren 29 Checking the Status of a Reopening Request 30 Responding to Medical Review Additional Documentation Requests 32 Accessing the MR ADR Response Form 32 Completing the MR ADR Response Form 33 Provider Information Section ereere renren 33 Patient amp Claims Information Section l rreren 33 Attachments Section ooo ccccccceccesceeeeeseeeeeeseeevereeeeeseeeverseceneeee 35 Submitting the MR ADR Response Form 35 Checking the Status of an MR ADR Response 37 DISCLAIMER This educational resource was prepared to assist Medicare providers and is not intended to grant rights or impose obligations CGS makes no representation warranty or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of these materials CGS encourages users to review the specific statutes regulations and other interp
25. emark of the American Medical Association Applicable FARS DFARS Restrictions Apply to Government Use Once all information is entered click Validate myCGS will validate the information entered for completeness and accuracy If information is missing or invalid you will receive a message identifying the fields that must be corrected If the information is complete and correct you will see this message at the top of the screen ccs Home Claims Remittance Eligibility Financial Tools Messages Forms P i i i User Provider Get Status You have 8 unread message s and 0 alerts Heip Go To Page Select Form ca 2S a l O O ll l ll 7 l lll lll l ee Your entries have been validated Please attach the required documents input your name and click Submit Supporting Documentation Section This section of the Reopening form allows you to attach documentation e g remittance advice medical records operative radiology reports you would like CGS to consider when processing your reopening You can attach up to 5 documents up to 5 MB each The documents must be in a PDF format To add an attachment select the Browse button and a window will open allowing you to locate the document you wish to add Select the document to attach it Repeat this process for each additional document you wish to attach Click the RED X to remove an attachment myCGS User Manual Page 23
26. er Option lanana anaha ALEA LEA LEA LEEA LEA EEA ELEI EEE EE n n 15 RROD HOR a ee ne A E A E EA 16 Stop Provider Level Offset Previously Requested ooo ooo coococeececee 18 Checking the Status of an e Offset Request 19 Submitting Reopening Requests erreren 20 Accessing the myCGS Reopening Form errn 20 Completing the Reopening Form ooo ooo ccccccccccsececeeesseeeeeetsceceeterseeevens 21 DISCLAIMER This educational resource was prepared to assist Medicare providers and is not intended to grant rights or impose obligations CGS makes no representation warranty or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of these materials CGS encourages users to review the specific statutes regulations and other interpretive materials for a full and accurate statement of their contents Although this material is not copyrighted the Centers for Medicare amp Medicaid Services CMS prohibit reproduction for profit making purposes myCGS User Manual Page 2 Forms Tab for Part B Providers CHAPTER 7 Single Beneficiary Reopening Form rreren 22 Provider Information Section errereen renn Za Beneficiary Information Section rererere rren 23 Claim Information Section 000000 errereen rrr 23 Supporting Documentation Section 23 Multiple Beneficiary Reopening Form 000020 ooo cc
27. er the Claims and Messages tabs Home Claims Remittance Eligibility Financial Tools Messages Forms i User Will Srath Provider Fredenck Mechcal Center PSC Logout You have O unread message s and O alerts fo GoTo Page SelectForm i e i E o Select Fomm Secure Forms Welcome to secure forms You can now submit forms to CGS Administrators securely through myCos We have several forms to select from and we continually add new forms Please check back often for new forms To begin please select form in the Go To Page field above Once you are on the Reopenings page click on the Reopenings link to access the form myCGS User Manual Page 20 Forms Tab for Part B Providers CHAPTER 7 Get Status You have 0 unread message s and O alerts Co Go To Page Select Form P a eopenings a a oe on A You may attach up to five PDF attachments to each form Each attachment can be up to 5 MB in sare The forms and attachments are automatically entered into our workflow This makes form processing more efficent and cost effective Reopenings ER 115 8 1000 Disclaimer About Us Contact Us Help Site Map 2014 COS Administrters LUC OGS A righta naaeary ed a z F wate Wwhes and Gling Provider Services provided A supported Er Palmetto OBA COMPLETING THE REOPENING FORM Once you select the form the myCGS Reopenings Request page
28. erify that the information entered and attachments are correct Clicking OK also allows you to electronically sign the form e Signature ib this information correct Please review your information and attachments carefully f they are comect please press Ok to submit H not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the infommation Cancel mse Ter X myCGS User Manual Page 34 Originated July 31 2012 Revised September 29 2015 2015 Copyright CGS Administrators LLC Forms Tab for Part B Providers CHAPTER 7 If corrections need to be made to the form or if any attachments need to be added or deleted click Cancel to return to the form After submitting the form you will be taken to the Messages tab where you will receive a message confirming receipt of the MR ADR Response form A second message will be sent which will include a Submission ID assigned to your request This is confirmation that the form was accepted and will be the final message received NOTE The second message can take up to 24hrs to be received Get Status You have 2 unread messages and O alerts Go To Page Select Form w MESSAGE INBOX ARCHIVED MESSAGES Click on the subject links to view mesages Bold links indicate new unread messages Delete Selected Tha S7 INIS Secure Form Confirmation apg TesFebTLIRZDESTION secure Form Received Toe Feb
29. es that need to be reopened on the claim please indicate the specific line numbers in the comment section Examples of request reasons include 1150 characters left CPT only copyright 2014 American Medical Association All rights reserved CPT is a registered trademark of the American Medical Association Applicable FARS DFARS Restrictions Apply to Government Use Once all information is entered click Validate myCGS will validate the information entered for completeness and accuracy If information is missing or invalid you will receive a message identifying the fields that must be corrected If the information is complete and correct you will see this message at the top of the screen CGS ome Claims Remittance Eligibility Financial Tools Messages Forms Support i EA i LLE User Provider You have 8 unread message s and 0 alerts Heip Go To Page Select Form _ BSS SS SBSBESBVSBESSSBVSBSBVVsVeaa sa sas SF Ft Your entries have been validated Please attach the required documents input your name and click Submit myCGS User Manual Page 27 Forms Tab for Part B Providers CHAPTER 7 Supporting Documentation Section This section of the Reopening form allows you to attach documentation e g remittance advice medical records operative radiology reports you would like CGS to consider when processing your reopening You can attach up to 5 documents up to 5 MB each The documents must be in a P
30. ess Ok to submit If not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the information Ok Cancel After submitting the form you will be taken to the Message tab Shortly after submission you will receive a confirmation message confirming receipt of the eOffset request A separate message will be sent to your inbox which will include a Submission ID assigned to your request See Messages in Chapter 6 for more details myCGS User Manual Page 15 Forms Tab for Part B Providers CHAPTER 7 AR Option Selecting the AR option allows you to request an immediate offset using the AR number assigned to the request Select Letter or AR Using the AR option will allow you to enter up to 10 AR numbers which are identified on an attachment to the demand letter to request an immediate offset ber 1234567391000P0B SS cris lates eric Hi Ng be i Aji From 1234567891000P0B JOHN A DOE 1234567594 Reason for Overpayment This claim adjustment is for the final Home Health episode Once the form for this option displays you will find the Contract Region Provider Name Provider Number PTAN and Provider NPI fields will show pre populated and identify the User s information You must complete the following fields to submit your eOffset request using myCGS e Requestor Name e Requestor Phone Number AR Number Name Upon entering the AR number the Date of
31. ete the following fields Beneficiary Name Beneficiary City State and Zip Code Beneficiary Medicare Number Beneficiary Phone Number Beneficiary Address Name Here 123 Steet Name City Name 12345 myCGS User Manual Page 26 Forms Tab for Part B Providers CHAPTER 7 Claim Information Section e Service Date From Select date from the calendar icon e Service Date To Select date from the calendar icon e Claim ICN This is the internal control number ICN of the original claim The ICN can be located on your remittance advice If you are unable to locate the ICN you may enter 13 Os zeroes to bypass the field e HCPCS Enter the applicable CPT HCPCS code Click Add Remove or Clear All to add remove or delete the code entered Reason for Request Enter the reason rationale for the reopening request in 1200 characters or less Hover your cursor over the Examples of request reasons include link for assistance If the reopening request is for multiple dates of services please enter all dates and applicable CPT HCPCS codes noting the correction being requested Claims Information Service Date From ios 14 X Service Date To O5 01 2014 Claim ICN NNN HCPCS Q cD Reason for Request The reason wae 99213 should be changed to CPT code for request must be the same reason 9923 for all claims listed Be specific in your request If you have multiple DOS or lin
32. etermination available to you ADR Letter Number This 3 digit number is located in the right margin near the body of the ADR letter NOTE Enter the LAST three digits only CPT HCPCS Code Enter the CPT HCPCS code and click ADD to populate the field NOTE If there are multiple CPT HCPCS codes for a single claim please respond to the ADR by one of the other methods identified in the letter Patient amp Claims Information HIC Number KAKKKRKKRA ICN 1234567890123 Re enter ICN 1234567890123 Date Of Service 02 02 7015 Date of Letter 02 05 2015 ADR Letter Number 123 BS SS 2 ee Ce ae es eee Cae 99213 PT Code s dour Clear All What is the performing provider PTAN XXXX Identify if a group PTAN is associated with the account If so enter the individual provider s PTAN Once all information is entered click Validate myCGS will validate the information entered for completeness and accuracy If information is missing or invalid you will receive a message identifying the fields that must be corrected If the information is complete and correct you will see this message at the top of the screen myCGS User Manual Page 33 Forms Tab for Part B Providers CHAPTER 7 You have O unread message s and O alerts Go To Page Select Form Your entries have been validated Please attach the required documents input your name and click Submit MR ADR Response J15 B A
33. ffset Offset a particular overpayment Enter one letter or up to 10 AR s per completed offset request Please allow 10 calendar days to process request It will be necessary to request an immediate offset on each PTAN NPI combination This ensures the appropnate validation process is completed Stop Provider Level Previously Requested It will be necessary to request an immediate offset on each PTAN NPI combination This ensures the appropriate validation process is completed This change wil affect new debts created on and after the date this request is processed Debts currently in an offset status will remain so until the debt has been satisfied Once you select an option a disclaimer box will display to confirm timeframes and to ensure the User has selected the correct form Piia aihe evil bet aa 1 Pe ot eet Piria lens DI Calera tli DO De Neg Th hange thet ane PTY combination wil titt new debe coeeied on aed after ther date i req Bp HAL gee i ee TA oe phat nell nein oF TRH resan iei the eee Lal valle oe eres corpo mare hee che bei Bee i fed Plast apie phe a ning perk keel ole tor hh PTAA D combinations only E ou hive heel TNA poe ced al aera amir yi E em cone a een E cance Provider Level Offset After you accept the disclaimer the Provider Level Offset form will display The Contract Region Provider Name Provider Number PTAN and Provider NPI fields will show pre populated and identify the User s informat
34. g documentation would include Attachment 1 a A Attachment z x x x OBO 2014 myCGS User Manual Page 25 Forms Tab for Part B Providers CHAPTER 7 Below the Attachments section is the Name field The first and last name of the person completing the form must be entered into this field MEDICARE SECONDARY PAYER REOPENING FORM When this option is selected a message box will display to verify the reopening request is related to an MSP situation If so simply click OK if not click Cancel to return to the Reopening Request page Medicare Secondary Payer Request A You have selected Medicare Secondary Payer MSP request Is this related to MSP If yes Click OK to continue If no click Cancel and select option 1 Provider Information Section You must complete the following fields e Provider Address 1 e Provider Phone Number Provider City Last 5 Digits of Tax ID e Provider State e National Provider Identifier NPI Provider Zip Code Some fields will be pre populated based on your myCGS account Provider Information Provider Name Provider Name Here Last 5 Digits of Tax ID HOX Provider Number NNNNNNNNNN NPI NNNNNNNNNN Provider Address 1 123 Street Name Provider Address 2 Provider City City Name Provider State ST Provider Zip Code 12345 Provider Phone Number 00 XXX 200Xx Beneficiary Information Section You must compl
35. gs Please review carefully to determine if your request is a Reopening Redetermination or Overpayment Recovery situation Request a reopening by selecting one of the following options Single Beneficiary Request a correction for one beneficiary one or multiple claims to maintain payment or pay additional money If this is related to Medicare Secondary Paper MSP use Option 3 Multiple Beneficiaries Request a correction to multiple beneficiaries by submitting a Remittance form or by submitting a spreadsheet with information to identify the claims to correct Medicare Numbers dates of service procedure codes and when possible the specific ICN to maintain payment or pay additional money D Medicare Secondary Payer Request Request a correction for one beneficiary one or multiple claims for Medicare Secondary Payer information such as updated records Liability Disability and Workman s Compensation issues to maintain payment or pay additional money If this is related to banenidlary use mpre 1 There are three different Reopening forms available Single Beneficiary Select this option to request a reopening of one or multiple claims for one beneficiary Multiple Beneficiaries Select this option to request a reopening for multiple beneficiaries myCGS User Manual Page 21 Forms Tab for Part B Providers CHAPTER 7 e Medicare Secondary Payer Request Select this option to request a reopening of
36. haracters or less Hover your cursor over the Examples of request reasons include link for assistance Reason for Request The reason All claims were denied as duplicate in error for request must be the same reason for all claims listed Be specific in your request If you have multiple DOS or lines that need to be reopened on the claim please indicate the specific line numbers in the comment section Examples of request reasons include 1155 characters left Once all information is entered click Validate myCGS will validate the information entered for completeness and accuracy If information is missing or invalid you will myCGS User Manual Page 24 Forms Tab for Part B Providers CHAPTER 7 receive a message indicating the information that must be corrected If the information is complete and correct you will see this message at the top of the screen Home Claims Remittance Eligibility Financial Tools Messages forms Support User Provider C Get Status You have 8 unread message s and O alerts gD Go To Page Select Form ke O O l l ll ll l ll l ll l ll Your entries have been validated Please attach the required documents input your name and click Submit TE T E SS SSS SS SS SS SSBB M Claim Information Section Since the request is for multiple beneficiaries either a remittance advice or spreadsheet must be attached identifying the claim ICN date of service
37. ion You must complete the following fields to submit your eOffset request using myCGS e Requestor Name e Requestor Phone Number Name After completing all required fields click Submit to submit the form myCGS User Manual Page 13 Originated July 31 2012 Revised September 29 2015 2015 Copyright CGS Administrators LLC Forms Tab for Part B Providers CHAPTER 7 Provider Level Offset Provider Mame Browder Number PTAN rea a a BBB a a M F Requestor Mame estor Phone Number A eo An e signature box will appear asking you to verify that the information entered is correct This ensures the signature requirement for all requests have been met Click OK if you agree or to return to the form to make corrections Signature E this information correct Please review your information carefully H it is correct please press Ok to submit if not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the information gt Ok Cancel After submitting the form you will be taken to the Message tab Shortly after submission you will receive a confirmation message confirming receipt of the eOffset request A separate message will be sent to your inbox which will include a Submission ID assigned to your request See Messages in Chapter 6 for more details Demand Letter Offset After you accept the disclaimer a window will
38. on gt Ok Cancel Upon submitting the form a message box will ask if there are additional ARs to enter If so press ADD myCGS will submit the ARs you entered then take you back to the form to enter more If there are no additional ARs to be entered press SUBMIT Do you have additional ARs to enter If so press ADD to continue If you are done press SUBMIT After submitting the form you will be taken to the Message tab Shortly after submission you will receive a confirmation message confirming receipt of the eOffset request A separate message will be sent to your inbox which will include a Submission ID assigned to your request See Messages in Chapter 6 for more details Stop Provider Level Offset Previously Requested Upon accepting the disclaimer the Stop Provider Level Previously Requested form will display The Contract Region Provider Name Provider Number PTAN and Provider NPI myCGS User Manual Page 17 Forms Tab for Part B Providers CHAPTER 7 fields will show pre populated and identify the User s information You must complete the following fields to submit your e Offset request using myCGS e Requestor Name e Requestor Phone Number Name pane ae ee einer ee aa agg Iygcess is completed Provider Level Previously Requested R wil be necessary to request an immediate offset on each PTAN NPI pereat bias ae ee a a mil cess i is completed This change wil affect new debts create
39. page click the link to access the form Go To Page C You have 0 unread message s and O alerts Help ay T i MR ADR Beginning January 2015 a new process will be implemented for all Part A B and HHH providers physicians and other suppliers On occasion CGS Medical Review areas need additional documentation for submitted claims CGS will send the provider a letter requesting the additional documentation This new process allows you to submit requested documentation to us electronically There may be required information that is necessary in order to submit this documentation Most of the information can be obtained from the ADR sent to you You may attach up to five PDF attachments Each attachment can be up to 5MB in size The forms and attachments are automatically entered in our workflow This makes form processing more efficient and cost effective MR ADR MR J15 B 3000 myCGS User Manual Page 31 Forms lab CHAPTER for Part B Providers COMPLETING THE MR ADR RESPONSE FORM When completing the MR ADR Response form please be sure to have a copy of the ADR letter to help ensure the form is completed accurately CGS Acrminstrators LLC MEDICARE PART B PO Box 20018 MEDICARE PART B a AY ax hashwite TN 37202 CENTERS POR MIDOCARE MEDODD seewets e Date of Letter Internal Control Number ICN First 13 digits ONLY vider p es eee eee m 1 e 125 Any Street 1 DATE 92 05 2015 i He
40. retive materials for a full and accurate statement of their contents Although this material is not copyrighted the Centers for Medicare amp Medicaid Services CMS prohibit reproduction for profit making purposes myCGS User Manual Page 3 Forms Tab for Part B Providers CHAPTER 7 Forms Tab The Forms tab allows providers to submit certain forms directly to CGS through the myCGS Web portal Currently 2 forms are available Redeterminations and eOffsets Reminder Provider Administrators have access to all tabs within myCGS Provider Users only have access to those tabs granted by their Provider Administrator If you are a Provider User and the Forms tab is grayed out but you believe you need access to the Forms Tab contact your Provider Administrator Home Claims Remittance Elgibdity Financial Tools Forms User Provider Get States You have unread message s and O alerts Secure Forms SUBMITTING A REDETERMINATION REQUEST The Forms tab option within myCGS allows Users to submit a Redetermination request 1st level of appeal to CGS using an electronic Redetermination Request Form In addition this tab allows Users to submit additional supporting documentation with their redetermination requests Users may also monitor the status of their redetermination requests using this option Accessing the myCGS Redetermination Form Once you access the Forms tab in the Go To page
41. rmination Request today Will it meet the 120 day timeliness requerement Simply enter the initial determination date on your Medicare Remittance Notice Medicare Summary Notice or Demand Letter myCGS User Manual Page 5 Forms Tab for Part B Providers CHAPTER 7 The Appeals Time Limit Calculator will display the last day to submit your redetermination request in order to meet timeliness requirements If your request is still within this timeframe return to the Secure Forms screen to complete and submit the Redetermination form in myCGS Completing the myCGS Redetermination Form Once you have determined that your redetermination request is timely click on the Redetermination 1st Level Appeal link To begin please select an answer to the questions from the drop down selections below Based upon the answer given for each of the questions the avaiable form s wil appear at the bottom of this box At this time only Appeals forms are available Select a Topic Appeals Select a Type First level appeal on a Medicare Claim To verify you are within tinvely filing requirements for this Appeal please use our Appeals Cabculator Is your appeal late over 120 days for a redetermination or over 365 days for a reopening No Redeternination 1 Level Appeal EA 315 B 1000 The myCGS Redetermination 1st Level Appeal form will appear There are four sections to the form 1 Beneficiary Information 2
42. s Cc GoTo Page Select Form The status of your request is displayed below Submission ID ANN NA AP A A Pe Pd Submission ID Status COMPLETED Riroper rings ae a Option Single Beneficiary Provider Information Last 5 Digets of Tax IDs ational Prowder Provider Number Identifier NPT PAN Pad Pd gM PTAN AINA MAP Provider Address 1 123 STREET NAME Provider Address 2 Provider City CITY NAME Provider State 3T Provider Phone Humber 615 555 5555 Provider Zip Cade 12345 Beneficiary Information Beneticiany Nace First Last Medicare Muriber NAINA A AA Beneficiary Address 1 456 STREET NAME Renehcuary Address 2 Beneliciany City CITY NAME Benehcary Stabe oT Beneficiary Phone Beneficiary Zip Code 12345 eee Qlaims Information Service Date From Os Os5 7014 Sarmvice Date To Os o5 2014 Claim IO PUM AA PA Pd Sd HCPCS AA AM Attached Fibs CPT only copyright 2014 American Medical Association All rights reserved CPT is a registered trademark of the American Medical Association Applicable FARS DFARS Restrictions Apply to Government Use If the reopening request is not valid and should be processed by other departments e g overpayments appeals you will see a TRANSFERRED status The status of requests transferred to other areas will no longer be available through myCGS You will receive information directly from those areas myCGS User Manual Page 30 Forms Tab for Part B Provi
43. s can also be tracked by clicking the Get Status button located on the upper right of your inbox Secure Form Completed request SPRNNNNNNNANN completed by CGS TASEEN NANNY NAS peach Wea ween Gh peck cate select the Messages tab an the Cie bi tele a na Skata 0 EA vee facile ati Wa Submission ID G CGS Administrators LLC Giris on iF P 66 z D n LT CO ieee pm h If you check the status by selecting the Get Status button you must enter the Submission ID assigned to your request in the Submission ID field and click Submit myCGS User Manual Page 29 Forms Tab for Part B Providers CHAPTER 7 Home Claims Remittance Eligibility Financial Tools Messages Forme Support seer Provider Get Status You have 7 unread message s and 0 alerts gD GoTo Page Select Form te Please enter the Submission ID assigned to your request and click Submit NOTE The Submission ID was assigned to your request when it was submitted online e g WContract Region 1304600502 auar wa gt Submission ID NNNNNNNNNNNNNNNN t Requires el oo A page will display with the Submission ID the status of the request and other information specific to the reopening request Once your request is processed and completed you will receive another message with the Subject Secure Form Completed in your message inbox You hase 7 unread message s and O alert
44. s you on how to view the status of your request Check the status from this screen by selecting the Get Status button or clicking on the Submission ID in the message C have 2 unread message s and O alerts EJ Go To page Sart Fam Subject Secure Form Confirmation assigned to your appeal request is 13150073000006 he status of your request select the Message Inbox tab Click on the Ge tus button Enter the Submission ID assigned to your appeal request in the Submission ID box Your Appeals Redeterminations request has been x di by CGS The Submission ID Thank you for using myCGs Message From CGS Administrators LLC If you check the status by selecting the Get Status button you must enter the Submission ID assigned to your redetermination in the Appeal DCN field and You bava umesd measiagels eed 0 alerte mase Go To page beled Form Viewing Redetermination Documents Whether you check the status by clicking the Get Status button or by selecting the myCGS User Manual Page 10 Forms Tab for Part B Providers CHAPTER 7 Submission ID within the message myCGS displays the status of your redetermination request It also gives you the option to view the Redetermination form you completed and any documents you attached to your request Simply click on the Submission ID that appears in the message You have 2 unread message s and 0 alerts Q Go To page Salert Fam Subject Secur
45. sections to the form 1 Provider Information 2 Patient amp Claims Information 3 Attachments and 4 Electronic Signature Each field marked with a RED asterisk is required Provider Information Section This section will be pre populated based on your myCGS account Provider Information Contract Region Part B Kentucky Provider Name CGS SUPERADMIN Provider Number PTAN XXXX National Provider Identifier NPI 7777777777 Patient amp Claims Information Section You must complete the following fields e Health Insurance Claim HIC Number Internal Control Number ICN The ICN is located at the top of the ADR letter NOTE Enter the first 13 digits ONLY myCGS User Manual Page 32 Forms lab CHAPTER 1 for Part B Providers e Date of Service Select the date from the calendar icon or enter in XX XX XXXX format Patient amp Claims Information HIC Number KKKKARKAKA ICH 1234567890123 Re enter ICH 1234567890123 Date Of Service Date of Letter o ADR Letter Number s Mo Tu We Th fr Sa 1 zi 3 a 5 6 7 CPT Code s Bi gl 40 141l 12 143 44 15 16l 17 18 19 Is this a group PTAH Date of Letter The letter date is located at the top of the ADR letter Select the date from the calendar icon or enter in XX XX XXXX format NOTE If the ADR letter is beyond the timeframe to respond a message will display letting you know and the options i e Reopening Red
46. sired attachments were included click OK to submit the Reopening form and all attachments If corrections need to be made to the form or if any attachments need to be added or deleted click Cancel to return to the form myCGS User Manual Page 28 Forms Tab for Part B Providers CHAPTER 7 After submitting the form you will be taken to the Message tab Shortly after submission you will receive a confirmation message confirming receipt of the reopening request A separate message will be sent to your inbox which will include a Submission ID assigned to your request The Submission ID may be used to track the status of your request See Messages in Chapter 6 for more details NOTE Upon submission of the Single Beneficiary and the Medicare Secondary Payer forms a second window will display asking if you have additional Reopening requests to submit If so myCGS will default back to the form allowing you to enter new beneficiary information The provider information will pre populated on the form If there are no additional requests to submit myCGS will default to the Messages tab as explained above CHECKING THE STATUS OF A REOPENING REQUEST The message with the Submission ID assigned to the reopening request provides instructions on how to view the status of your request You can check the status from this screen by clicking on the Submission ID in the message NOTE The statu
47. t status C Youhave 3 unread message s and O alerts EA Go To page Suea Fome T S S 33537535 MESSAGE INBOX ARCHIVED MESSAGES Cick on the subject links to view messages Bold links indicate new unread messages In Message inbox 2 tems found caplaying all kema 1 E Date C Secure Farm Fri Aug 23 15 09 41 EDT 2003 The message will contain a Subject indicating Secure Form Received to advise you that your redetermination request has been received It will not display a Submission ID until one has been assigned by CGS Once CGS has assigned the Submission ID you will receive another message with a link myCGS User Manual Page 9 Forms Tab for Part B Providers CHAPTER 7 Secure Form Confirmation under the Subject column Click on this link to view the message The message identifies the DCN assigned to your redetermination request i e Appeal DCN and includes instructions on how to check the status Got Status You have 3 unread message s and 0 alerts Heip Go To page Select Form MESSAGE INBOX ARCHIVED MESSAGES Cick on the subject links to view messages Bold inks indicate new unread messages Re AEA In Message inbox 2 ems found displaying all tems C Secure Form Thu May 30 14 06 45 EDT 2003 Secure Form M S47E9A 1315007 PHOS Confirmation Checking the Status of a Redetermination Request The message with the Submission ID assigned to the redetermination instruct
48. tatus can also be tracked by clicking the Get Status button located on the upper right of your inbox myCGS User Manual Page 18 Forms Tab for Part B Providers CHAPTER 7 E Offuet Form Confirmation Tour Offset requett has been recelved by CGS The Submision D atiigned to your Offset request K WiZ3456789123456 To check the status of your request select the Messages tab Click on thr Get Satie button Enter the Submision D aligned to your Offset request in the Submission D bag Thank you for wing myp0G5 Mesage From COS Administrators LLC Merise To Qabi234 If you check the status by selecting the Get Status button you must enter the Submission ID assigned to your eOffset request in the Submission ID field and click Submit Home Claims Remittance Eligibility Financial Tools Messages Forms Support User Provider Get States You have 8 unread message s and 0 alerts EE Go To page SetectFom Pease enter the Submision ID asegqned to your request and cick Submet NOTE The Submession ID was assigned to your request when it was a submitted iss u WContract Region cn lt _ _i_ a 2 2 se eS Se Se SS m A page will display with the Submission ID the status of the request the date time the request was received the type of eOffset request submitted and the User s information You have 8 unread rmessage s and O alerts Go To page Select Foam
49. ttachments Section This section of the MR ADR Response form allows you to attach the documentation requested in the ADR letter e g medical records operative radiology reports directly to the form You can attach up to 5 documents up to 5 MB each The documents must be in a PDF format NOTE At least ONE document must be attached to the form To add an attachment select the Browse button and a window will open allowing you to locate the document within your system that you wish to add Select the document to attach it Repeat this process for each additional document you wish to attach Click the RED X to remove an attachment Attachments Please attach all documentation up to 5 MB each that you would like included in this Med Review Response You should also include any documentation to support your Med Review request Attachment 1 CAusersPutic document Browse X Attachment 2 Srowse X Attachment 3 Browse X Attachment 4 Browse X x Attachment 5 trowse Submitter Name Part amp Provider Date 02 13 2015 Below the Attachments section is the Name field The first and last name of the person authorized to complete the form must be entered into this field SUBMITTING THE MR ADR RESPONSE FORM Once all information has been entered the form validated and all necessary documents have been attached click the Submit button An e Signature box will display asking you to v
50. ubmitting a Redetermination Request Form Once all requested information has been entered and all necessary documents have been attached click on the Submit button myCGS User Manual Page 8 Originated July 31 2012 Revised September 29 2015 2015 Copyright CGS Administrators LLC Forms Tab for Part B Providers CHAPTER 7 08 23 2013 An e signature box will appear asking you to verify that the information entered and attachments are correct This ensures the signature requirement for all redetermination requests has been met Is this information correct Please review your information and attachments carefully If they are correct please press Ok to submit if not press Cancel By clicking on the Ok button you are signing the form and are authorized to submit the information gt ox tancat If the information was entered correctly and all desired attachments were included click OK to submit the Redetermination 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 Redetermination Submission Message and Submission ID After submitting the redetermination form you will receive a message in your myCGS inbox You can access the message by either clicking on the Messaging tab located in the menu or clicking the link displayed in the Message Bar ee ee ee ee Oo o Ge
51. will appear This page explains timeframes and provides examples of valid Reopening requests These details must be considered prior to submitting a request Forms User Provider You have unread messagets and 0 alerts j Heip Go To Page Reopenings Request The Reopenings requests must be submitted within 12 months from the original claim remittance date Claims which denied for no appeal or adjustment rights are not considered eligible for timely filing A Reopenings form should be submitted for the following situations so long as Medicare has not requested money to be returned Minor billing or clerical errors contractor error situations timely filing denials Medicare Secondary Payer requests Beneficiary or Provider record updates that will result in the same or additional money to be paid Clearinghouse or provider duplicate claim submission errors should not be adjusted through the Reopenings process Additionally claims which previously denied as ineligible for adjustment or appeal MA130 return reject etc and were not the result of contractor error should not be adjusted through the Reopenings process In these cases the claims should be refiled as new claims Corrections which will result in Medicare requesting money back should be submitted to the Overpayment Recovery department Submission of medical documentation with no claim corrections requested are not generally Reopenin
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