Medicare Claim Decision Guide (CGS – DME MAC)
Quick Decision Reference
Use this guide to quickly determine whether you should submit a Reopening, Redetermination, or Reconsideration for Medicare (CGS) DME claims.
Step 1 — Identify the Issue
Reopening
Use when the problem is strictly clerical, with no medical judgment involved.
Deadline: within 1 year (can exceed with good cause).
Examples:
- Wrong modifier
- Wrong DOS
- Units entered incorrectly
- ICD-10 typo
- Wrong NPI
Rule: If you can fix it without sending clinical documents, it’s probably a reopening.
Redetermination (Level 1 Appeal)
Use when documentation was missing, incomplete, or not submitted during the first claim.
Deadline: 120 days from the Remittance Advice.
Examples:
- Missing POD
- Missing sleep study
- Missing F2F
- CMN / detailed written order not included
- Additional medical necessity documentation now available
Reconsideration (Level 2 Appeal)
Use when CGS has already reviewed the documentation during Redetermination and still denied.
Deadline: 180 days from Level 1 decision.
Examples:
- You disagree with CGS’s interpretation of medical policy
- Documentation is strong, but denial was upheld
- LCD/NCD criteria dispute
Handled by: Qualified Independent Contractor (QIC)
Step 2 — Quick Logic Guide
Super-Fast Appeal Logic
- Was this my typo? → Reopening
- Did CGS want docs I didn’t send? → Redetermination
- Did CGS see everything and still say “nope”? → Reconsideration
Deadlines Cheat Sheet:
- Reopening → 1 year
- Redetermination → 120 days
- Reconsideration → 180 days
Step 3 — Summary Table
Summary
Action Use When Reviewed By Deadline Reopening Clerical errors only CGS 1 year Redetermination Missing / insufficient documentation CGS 120 days Reconsideration Appeal after redetermination QIC 180 days