You can find the FCN on your remittance advice. The Pricing screen in myCGS gives you a direct link to the fee schedule page on our website. To access pricing information, select the Pricing option in the Finance menu. From the Pricing screen, select the pricing hyperlink. A new window will open, taking you directly to the Jurisdiction B or C fee schedule page on www. The status of an EFT request submitted to any other contractor is not available. The Reprocessing menu in myCGS gives you the ability to view the status of Redetermination and Reopening requests and the ability to submit Redeterminations, Reopenings, and Claim Correction requests.
There are two main menu options in the Claim Preparation menu: Redeterminations and Reopenings , each of which have submenus which contain options for status or form submissions. Refer to the sections below for detailed information about each of the Reprocessing menu options. Use the Form Submission screen to submit a new Redetermination request.
Refer to the sections below for details. The Redeterminations Status screen provides current status of redetermination requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected.
To search for Redetermination status, go to the Reprocessing menu, select Redeterminations Status , and then enter the following information:. To view the attached documents, press the View button in the Documents column. A popup window will appear on screen, showing a list of any documents that are attached to the request.
You can then press the download icon next to the document you wish to view to open the document in a new window. This will include any documents you have submitted with your original request and any letters sent to you by CGS. For instance, if you search for Redeterminations Status in myCGS and there are other Redeterminations cases on file matching your search, then myCGS may also display documents and letters related to those cases.
For information about the Redeterminations process, refer to Appeals section of our website www. If you need access, please contact your DA. In order to initiate your request, the original claim in question must have already completed processing and must be eligible for a Redetermination. If the claim is still in process, you must wait for it to complete processing before submitting your request.
If a Redetermination cannot be requested for the claim you select for any reason, you will receive an error message with instructions. To submit a Redetermination in myCGS, follow the steps below. The first step in requesting a Redetermination in myCGS is to select the claim or claims you wish to include in your request. You can find your claim using either a regular Claim Status search via the Claims menu—refer to the Claims section in this manual or through the Redeterminations Form Submission screen in the Reprocessing menu.
Either method will take you to the same Redeterminations Request Form after you have found and selected your claim. From the Claim Status screen, select your claim s by pressing the Redeterminations button on the Claim Status Summary screen. After pressing the Redeterminations button, you must select the claim lines you wish to include in your request.
After selecting your claim lines, press the Next button. This will take you to the Redeterminations Request Form. If you wish to include more than one claim in your request, continue to add more CCNs until all of the claims you need to appeal are included. Once you have added a CCN successfully, it will appear on the screen with a green checkmark next to it, as shown in the following image. If the claim in question is past the timely filing limit for submitting a Redetermination request, the Past Timely popup message will appear.
If you have good cause to submit your request past the timely limit, enter your reason in the Past Timely window and press Save.
The supplier and beneficiary information sections will be auto-populated based on your user information and the claim s you've selected. Complete the rest of the form just as you would complete the paper version of the Redeterminations Request Form. The final step before submitting your request is to attach your supporting documentation. To upload your files, press the Browse button at the bottom of the form.
After pressing the Browse button, a navigation window will pop up allowing you to select the files you wish to attach and submit with your request. After selecting your documents, myCGS will list the files under the Browse button on the screen. After pressing the Submit button, your request will be submitted to CGS and processed just like a Redetermination request that was submitted via mail or fax. You can check the status of your request using the Redeterminations Status screen.
Please allow three business days for submitted requests to reflect in the system. Use the Form Submission screen to submit a new Reopening request. Use the Claim Correction screen to make simple claim corrections. The Reopenings Status screen provides current status of reopening requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected.
To search for Reopening status, go to the Reprocessing menu, select Reopenings Status , and then enter the following information:. For instance, if you search for Reopenings Status in myCGS and there are other Reopenings cases on file matching your search, then myCGS may also display documents and letters related to those cases.
For information about the Reopenings process, refer to the Reopenings section of our website www. Note that if a claim is eligible for a simple claim correction, then using the Claim Correction screen in myCGS is the fastest and easiest way to reopen and correct your claim. Refer to the Claim Correction section below. You should use the Reopenings Form Submission only when a simple claim correction is not an option.
In order to initiate your request, the original claim in question must have already completed processing and must be eligible for a Reopening. If a Reopening cannot be requested for the claim you select for any reason, you will receive an error message with instructions.
To submit a Reopening in myCGS, follow the steps below. The first step in requesting a Reopening in myCGS is to select the claim or claims you wish to include in your request. You can find your claim using either a regular Claim Status search via the Claims menu—refer to the Claims section in this manual or through the Reopenings Form Submission screen in the Reprocessing menu. Either method will take you to the same Reopenings Request Form after you have found and selected your claim. From the Claim Status screen , select your claim s by pressing the Reopenings button on the Claim Status Summary screen.
After pressing the Reopenings button, you must select the claim lines you wish to include in your request. This will take you to the Reopenings Request Form. Complete the rest of the form just as you would complete the paper version of the Reopenings Request Form. After pressing the Submit button, your request will be submitted to CGS and processed just like a Reopenings request that was submitted via mail or fax. You can check the status of your request using the Reopenings Status screen.
This is similar to a telephone reopening, but done in the web portal instead of over the phone. Only simple corrections can be made through this process.
For more complicated claim adjustments or for a claim appeal, you will need to submit a reopening or redetermination request whichever is appropriate for the situation. Corrections to diagnosis codes must be submitted through Redeterminations.
In order to initiate a claim correction, the original claim must have already completed processing. If the claim is still in process, you must wait for it to complete processing before submitting a correction. Duplicate claims and claims which have already had an adjustment initiated through a reopening, appeal, or other adjustment process are not eligible for correction in myCGS.
Claims that completed processing over one year ago are not eligible for correction. To initiate a claim correction in myCGS, follow the steps below. You can find your claim using either a regular Claim Status search via the Claims menu—refer to the Claims section in this manual or through the Claim Correction screen in the Reprocessing menu.
Either method will take you to the same Claim Correction screen after you have found and selected your claim. If you begin on the Claim Status screen, search for your claim as you normally would when checking claim status, and then press the Claim Correction button on the Claim Status Summary screen.
If you begin on the Claim Correction screen, search for your claim using the same data as you would when searching for claim status. The Claim Correction search screen behaves exactly the same way as the Claim Status screen.
Once you have found your claim, press the Claim Correction button. After you have found the claim that needs correction and pressed the Claim Correction button, you will be taken to the Claim Correction screen, where you can make your request. Once you're on the Claim Correction screen, myCGS will present the claim that you've selected for adjustment.
All fields that are eligible for correction will be editable. Make as many changes to your claim as you need you must make at least one change. After you have updated the field or fields you need to change, enter the reason why you are making the correction in the Reason for Claim Correction field. Please be sure to keep a copy of the confirmation number for your records. If you have a question about the adjusted claim and need to call Customer Service, you will need to reference the confirmation number.
Use the print icon in the top right corner of the screen to print a copy or save a PDF of the confirmation screen. You can press Enter if your cursor is in the Reason for Claim Correction field to create a paragraph break, but if your cursor is anywhere else on the screen, pressing Enter may submit your request.
Be careful not to press Enter until you are ready to submit your claim correction, otherwise you may submit your request prematurely. Note that most reopening requests are completed in 10—14 days. When checking status, you can use the confirmation number you received as the DCN in your reopening search or you can search using the CCN.
When you search for claim status, you will see both your original claim and your adjusted claim. The adjusted claim will show the current status of your claim correction. Redeterminations Status The Redeterminations Status screen provides current status of redetermination requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected.
Reopenings Status The Reopenings Status screen provides current status of reopening requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected.
The patient's first name, last name, date of birth, and social security number are required to get a unique match. After entering all of the required information, check the box which says "I am not a robot. It also informs you of our holiday closure schedule.
Currently this feature is used exclusively for Targeted Probe and Educate TPE cases in which you have already responded to an ADR request, but our Medical Review staff needs additional information for instance, when your ADR response did not include all requested documents or information.
When you receive a message, you have five business days to respond to the request; after 10 business days the message is deleted. When a message is generated to you by CGS staff, you will receive email notification from myCGS stating that you have a new message. You cannot initiate a message yourself in myCGS, only respond to a message we have sent regarding a claim.
End Users by default do not have access— DAs must specifically give End Users access to secure messaging in order for them to access the inbox. To access your inbox, select the inbox icon in the top-right corner of your screen you can access your inbox whether you have any unread messages or not. Note that the inbox itself is jurisdiction-neutral, meaning it doesn't matter if you are currently logged into Jurisdiction B or Jurisdiction C.
From the inbox, you will see the following information for each message you have:. Click on the desired message to open it. If you hover your cursor over the message, you will also have the option of a quick reply or delete button. After selecting a message, a popup window will appear on your screen showing you the full message, as well as the following information about the message and claim in question:.
Please respond to all messages sent to you within five business days. All messages are automatically deleted from myCGS 10 business days after they are sent to you.
Note that "business days" are Mondays through Fridays; holidays are not taken into account. To respond to a message in myCGS, press the Reply button. The Secure Message Form window will appear, where you can enter text and attach documents.
All responses must include at least one attachment. Enter any message you wish to include in the "Message" text box up to characters , and then press the Browse button to add your attachments.
After selecting your documents, myCGS will list the files you have ready to submit. If you wish to save a copy of your response, press the Export button to save your message as a PDF. After pressing Submit, a popup message will appear asking if you have attached all of your documentation.
You will receive a message confirming your response with the time and date of the submission. Note that the daily response cut off time is pm Central Time—any response submitted after pm Central Time is considered to be received the following business day.
CGS staff will then review your response and process the claim appropriately. If you wish to view your response after you have submitted, open the message from your inbox again. You will notice that the Reply button has changed to a My Response button. Press the My Response button to view your response. You will then also be able to export your response if you did not do so previously.
Accessing your Inbox To access your inbox, select the inbox icon in the top-right corner of your screen you can access your inbox whether you have any unread messages or not. Viewing Messages After selecting a message, a popup window will appear on your screen showing you the full message, as well as the following information about the message and claim in question:. There are several options in the My Account menu, including:.
When you are finished viewing any screen within the My Account section, select the Home menu to return to the myCGS home page, where you can continue to use the functions and features of myCGS. Passwords are an important part of securing both beneficiary data and your company's data. Your myCGS password should be kept up to date changed every 60 days and should be known only to you.
Your account will be locked if you enter your password incorrectly three consecutive times within a minute period. We recommend that if you have two consecutive unsuccessful login attempts that you do one of the following to prevent being locked out:. When you change your password, you cannot reuse any of your previous 12 passwords. Additionally, your new password must contain at least six different characters than your previous password, or if you reuse the same characters, they must be in a different position in the password.
For example, if your previous password started with the letter P, your new password should start with a different character, but you can still use the letter P in a different position of the password. If you attempt to change to a new password of Portal 92, myCGS will give you an error message stating that you need to use different characters for your password. This is due to the fact that six characters "Portal" are the same characters in the same position as your previous password.
If you instead change your password to Latrop 92, this password would be accepted because even though six of the same characters are reused, they are in different positions. Note that myCGS includes an optional suggested password in case you are having difficulty creating your own password see the Password Suggestion section below.
When changing your password, myCGS offers an optional "password suggestion" that you can use as your new password. To use the password suggestion, follow these steps:. We recommend that you set up at least two forms of MFA so that you always have a backup.
If you use a cell phone carrier other than one of the four service providers listed, choose the service provider network which is used by your carrier to provide service. Monday through Friday, April 1 to September Blue Shield is committed to non-discriminatory behavior in conducting business with all of its members.
Blue Shield is committed to treating all with whom work force members come into contact, with respect and dignity. All providers are required to have policies which demonstrate that they treat any member in need of health care services with the same respect and dignity. Senior Blue HMO and Freedom HMO plan options provide quality, comprehensive health care services to people who are eligible for Medicare, with an emphasis on prevention, health maintenance and early diagnosis and treatment.
Applicants must be entitled to Part A, enrolled in Part B, and continue to pay any required Medicare premiums. Beneficiaries who meet the eligibility requirements cannot be denied membership into the plan. Forever Blue Medicare PPO offers comprehensive benefits while also giving members the flexibility of choosing a provider from our network, obtaining specialist services without a referral, and the option to seek out-of-network care.
Federal regulations prohibit Medicare Advantage MA organizations, including Highmark Blue Shield of Northeastern New York, from paying for services rendered by physicians or practitioners who have chosen to opt out of the Medicare program, except in limited circumstances. Opting out is not the same as "non-participating.
CMS regulations for opt-out physicians or practitioners also require a "private contract" between the Medicare beneficiary and the physician or practitioner who opted out of Medicare.
A physician or practitioner may cancel opt out by submitting written notice to the Medicare Administrative Contractor not later than 30 days before the end of the current two-year opt-out period. If a physician or practitioner wants an early termination of their opt-out status, there are specific Medicare requirements that must be met timely and the physician or practitioner must not have previously opted out.
Chapter 15 can be accessed online at cms. If your status with Medicare changes, you must notify your Provider Network Management and Operations Specialist promptly at More information regarding New York state physicians or practitioners who opt out of Medicare is available from the local Medicare Administrative Contractor, National Government Services, at ngsmedicare.
Any service not provided or arranged by a contracting medical provider, or prior authorized except for emergency or urgent care situations or for out-of-area renal dialysis , are not covered by Senior Blue HMO or Freedom HMO-POS. This excludes emergency or urgent care situations or for out-of-area renal dialysis.
There is a limit to what our plan will cover under the Point-of-service POS benefit. Not all services are available under the Point-of-service POS benefit. Forever Blue PPO members may see medical providers that are not part of the network, but they will pay a higher cost-share. Medical Protocols are available on our website. Unless separate Medicare Advantage criteria are listed in the protocol, the criteria indicated are applicable to services provided in the local Medicare Advantage operating area for Medicare Advantage members.
This information in our protocols is designed to give you a concise, quick overview of the medical criteria we use to determine if a service is considered medically necessary under our Medicare Advantage contracts. Drugs administered or dispensed while the member is a patient in a hospital, nursing home, doctor's office, outpatient clinic, or other institution are not covered under this benefit.
The member, however, may be entitled to benefits under his or her basic medical contract. The Drug Formulary promotes the safe and effective use of drug therapies by helping physicians select the drug product s considered most beneficial to their patient populations. The Formulary contains a listing of approved or preferred medications. This committee consists of physicians, pharmacists, and other appropriate professional staff. The goal of the Formulary is to improve the value of pharmaceutical care delivered through proper consideration of both quality-of-care and economic issues.
For the latest pharmacy information, providers and members may visit our Medicare website. At the point of dispensing, the pharmacy will receive a message each time a non-Formulary medication is being filled.
If you are the prescriber, the pharmacist may contact you prior to dispensing to discuss Formulary alternatives. Please consider the appropriateness of Formulary treatment options for each patient. Many times a therapeutic switch can be made that will offer the patient the same outcomes to which they are accustomed. All prescription drug information including the drug formulary, monthly notice of formulary change document, drug preauthorization requirements, and step therapy guidelines are available online at bsneny.
The Program is tailored to meet the individual needs of our members. Our Care Management, Case Management, and Operations and Regulatory Compliance Units use an integrated process to help assure access to medical care for both members and providers. We have initiated and carried out such a program in a manner designed to meet the goals and objectives of our Corporation.
The focus of the Health Care and Service Quality Improvement program is to assess and improve, on a continuous basis:. Expansion areas will be included in all Quality Improvement initiatives. The Health Care and Service Quality Improvement Program includes organizational wide activities, a focus on trend analysis and development of interventions that improve the quality of care and service provided to our members.
In particular:. For authorized services provided by a non-participating Forever Blue PPO physician, payment will be made according to Medicare reimbursement policies. Participating physicians, suppliers, and providers who consider charging Medicare patients additional fees should be mindful that they are subject to civil money penalties if they request any payment for already covered services from Medicare patients other than the applicable deductible and coinsurance. Members may not receive an identification card prior to their effective date of coverage.
A proposed effective date letter and a copy of the enrollment application are mailed to the member while Blue Shield is processing the member's application. Hours of operation are 8 a. Patients should be asked to present their ID card at the time of service to assist in:. Possession of a member ID card does not guarantee eligibility for benefits, coverage or payment.
Please verify eligibility status at the time of delivery of service or admission to a hospital or other facility. A Medicare ID card alone is not proof of eligibility. According to the CMS Claims Processing Manual chapter 30, section , the MOON form must be given to all Medicare beneficiaries receiving observation services for more than 24 hours who are not an inpatient of your facility. After selecting your history type, enter the rest of the required search information, as detailed in the sections below.
The following image shows an example of claim history for a beneficiary who received diabetic shoes A in You can use this information on a pre-claim basis in order to determine if a beneficiary has previously received a specific item.
Using the claim history search can help you avoid same or similar equipment denials. Using both of these options in myCGS will give you a more complete picture of a beneficiary's equipment history.
To search for claim history, go to the Claim Preparation menu, select Claim History , and then enter the following information:. The Prior Authorization Status screen in myCGS allows you to view the status of any Prior Authorization request you have submitted to Jurisdiction B or C depending on which jurisdiction you have selected.
To search for Prior Authorization status, select Prior Auth from the Claim Preparation menu, choose Status in the Prior Auth sub-menu, and then enter the following information:. After pressing the Submit button, myCGS will return the following information:. To view the Prior Authorization decision letter, press the View link in the documents column.
To submit a Prior Authorization request, select Prior Auth from the Claim Preparation menu, choose Form Submission in the Prior Auth sub-menu, and then enter the following information:. On the PAR Coversheet, complete all of the required information, and attach your supporting documentation. To attach documents, press the Upload button.
After pressing the Upload button, a navigation window will pop up allowing you to select the files you wish to attach and submit with your request. After selecting your documents, myCGS will list the files under the Upload button on the screen.
Verify that all of the appropriate files have been selected and then press the Submit button to submit your request. If you need to attach more documents or wish to cancel your request, press No. You will receive a message stating that your request was submitted successfully, with the time and date of the submission. After submitting your request, you can use the Prior Authorization Status screen to check the status of your request; however, it will take up to three business days after submission before the status of your request is available.
After submitting your request, you can use the ADMC Status screen to check the status of your request; however, it will take up to three business days after submission before the status of your request is available. To view status of a Prior Authorization request, go to the Claim Preparation menu, choose Prior Auth, and then select the Status sub-menu.
Prior Authorization information is also available in Chapter 9 of the Supplier Manual. The Checks screen allows you to see the checks that have been issued to you recently, as well as any outstanding not cashed checks. The Checks screen allows you to see the last five issued checks issued to your account by CGS, as well as outstanding checks that have been issued in the last 30 days. To search for your checks, select the Checks option in the Finance menu.
Note that if you have outstanding checks that are greater than 30 days old, they will not be reflected in the check results. The Offsets screen gives you access to information about overpayments that have resulted in an offset. To search for an offset, select the Offsets option in the Finance menu. Once on the Offsets screen, enter the FCN of your offset. You can find the FCN on your remittance advice.
The Pricing screen in myCGS gives you a direct link to the fee schedule page on our website. To access pricing information, select the Pricing option in the Finance menu. From the Pricing screen, select the pricing hyperlink. A new window will open, taking you directly to the Jurisdiction B or C fee schedule page on www. The status of an EFT request submitted to any other contractor is not available.
The Reprocessing menu in myCGS gives you the ability to view the status of Redetermination and Reopening requests and the ability to submit Redeterminations, Reopenings, and Claim Correction requests. There are two main menu options in the Claim Preparation menu: Redeterminations and Reopenings , each of which have submenus which contain options for status or form submissions.
Refer to the sections below for detailed information about each of the Reprocessing menu options. Use the Form Submission screen to submit a new Redetermination request. Refer to the sections below for details. The Redeterminations Status screen provides current status of redetermination requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected.
To search for Redetermination status, go to the Reprocessing menu, select Redeterminations Status , and then enter the following information:. To view the attached documents, press the View button in the Documents column. A popup window will appear on screen, showing a list of any documents that are attached to the request.
You can then press the download icon next to the document you wish to view to open the document in a new window. This will include any documents you have submitted with your original request and any letters sent to you by CGS. For instance, if you search for Redeterminations Status in myCGS and there are other Redeterminations cases on file matching your search, then myCGS may also display documents and letters related to those cases. For information about the Redeterminations process, refer to Appeals section of our website www.
If you need access, please contact your DA. In order to initiate your request, the original claim in question must have already completed processing and must be eligible for a Redetermination. If the claim is still in process, you must wait for it to complete processing before submitting your request. If a Redetermination cannot be requested for the claim you select for any reason, you will receive an error message with instructions.
To submit a Redetermination in myCGS, follow the steps below. The first step in requesting a Redetermination in myCGS is to select the claim or claims you wish to include in your request. You can find your claim using either a regular Claim Status search via the Claims menu—refer to the Claims section in this manual or through the Redeterminations Form Submission screen in the Reprocessing menu. Either method will take you to the same Redeterminations Request Form after you have found and selected your claim.
From the Claim Status screen, select your claim s by pressing the Redeterminations button on the Claim Status Summary screen. After pressing the Redeterminations button, you must select the claim lines you wish to include in your request.
After selecting your claim lines, press the Next button. This will take you to the Redeterminations Request Form. If you wish to include more than one claim in your request, continue to add more CCNs until all of the claims you need to appeal are included.
Once you have added a CCN successfully, it will appear on the screen with a green checkmark next to it, as shown in the following image. If the claim in question is past the timely filing limit for submitting a Redetermination request, the Past Timely popup message will appear. If you have good cause to submit your request past the timely limit, enter your reason in the Past Timely window and press Save.
The supplier and beneficiary information sections will be auto-populated based on your user information and the claim s you've selected. Complete the rest of the form just as you would complete the paper version of the Redeterminations Request Form.
The final step before submitting your request is to attach your supporting documentation. To upload your files, press the Browse button at the bottom of the form. After pressing the Browse button, a navigation window will pop up allowing you to select the files you wish to attach and submit with your request. After selecting your documents, myCGS will list the files under the Browse button on the screen.
After pressing the Submit button, your request will be submitted to CGS and processed just like a Redetermination request that was submitted via mail or fax. You can check the status of your request using the Redeterminations Status screen.
Please allow three business days for submitted requests to reflect in the system. Use the Form Submission screen to submit a new Reopening request.
Use the Claim Correction screen to make simple claim corrections. The Reopenings Status screen provides current status of reopening requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected.
To search for Reopening status, go to the Reprocessing menu, select Reopenings Status , and then enter the following information:. For instance, if you search for Reopenings Status in myCGS and there are other Reopenings cases on file matching your search, then myCGS may also display documents and letters related to those cases. For information about the Reopenings process, refer to the Reopenings section of our website www.
Note that if a claim is eligible for a simple claim correction, then using the Claim Correction screen in myCGS is the fastest and easiest way to reopen and correct your claim. Refer to the Claim Correction section below. You should use the Reopenings Form Submission only when a simple claim correction is not an option.
In order to initiate your request, the original claim in question must have already completed processing and must be eligible for a Reopening. If a Reopening cannot be requested for the claim you select for any reason, you will receive an error message with instructions.
To submit a Reopening in myCGS, follow the steps below. The first step in requesting a Reopening in myCGS is to select the claim or claims you wish to include in your request. You can find your claim using either a regular Claim Status search via the Claims menu—refer to the Claims section in this manual or through the Reopenings Form Submission screen in the Reprocessing menu.
Either method will take you to the same Reopenings Request Form after you have found and selected your claim. From the Claim Status screen , select your claim s by pressing the Reopenings button on the Claim Status Summary screen. After pressing the Reopenings button, you must select the claim lines you wish to include in your request. This will take you to the Reopenings Request Form. Complete the rest of the form just as you would complete the paper version of the Reopenings Request Form.
After pressing the Submit button, your request will be submitted to CGS and processed just like a Reopenings request that was submitted via mail or fax. You can check the status of your request using the Reopenings Status screen.
This is similar to a telephone reopening, but done in the web portal instead of over the phone. Only simple corrections can be made through this process. For more complicated claim adjustments or for a claim appeal, you will need to submit a reopening or redetermination request whichever is appropriate for the situation. Corrections to diagnosis codes must be submitted through Redeterminations. In order to initiate a claim correction, the original claim must have already completed processing.
If the claim is still in process, you must wait for it to complete processing before submitting a correction.
Duplicate claims and claims which have already had an adjustment initiated through a reopening, appeal, or other adjustment process are not eligible for correction in myCGS.
Claims that completed processing over one year ago are not eligible for correction. To initiate a claim correction in myCGS, follow the steps below. You can find your claim using either a regular Claim Status search via the Claims menu—refer to the Claims section in this manual or through the Claim Correction screen in the Reprocessing menu.
Either method will take you to the same Claim Correction screen after you have found and selected your claim. If you begin on the Claim Status screen, search for your claim as you normally would when checking claim status, and then press the Claim Correction button on the Claim Status Summary screen.
If you begin on the Claim Correction screen, search for your claim using the same data as you would when searching for claim status. The Claim Correction search screen behaves exactly the same way as the Claim Status screen.
Once you have found your claim, press the Claim Correction button. After you have found the claim that needs correction and pressed the Claim Correction button, you will be taken to the Claim Correction screen, where you can make your request.
Once you're on the Claim Correction screen, myCGS will present the claim that you've selected for adjustment. All fields that are eligible for correction will be editable. Make as many changes to your claim as you need you must make at least one change.
After you have updated the field or fields you need to change, enter the reason why you are making the correction in the Reason for Claim Correction field. Please be sure to keep a copy of the confirmation number for your records.
If you have a question about the adjusted claim and need to call Customer Service, you will need to reference the confirmation number. Use the print icon in the top right corner of the screen to print a copy or save a PDF of the confirmation screen. You can press Enter if your cursor is in the Reason for Claim Correction field to create a paragraph break, but if your cursor is anywhere else on the screen, pressing Enter may submit your request.
Be careful not to press Enter until you are ready to submit your claim correction, otherwise you may submit your request prematurely. Note that most reopening requests are completed in 10—14 days. When checking status, you can use the confirmation number you received as the DCN in your reopening search or you can search using the CCN. When you search for claim status, you will see both your original claim and your adjusted claim.
The adjusted claim will show the current status of your claim correction. Redeterminations Status The Redeterminations Status screen provides current status of redetermination requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected. Reopenings Status The Reopenings Status screen provides current status of reopening requests that you have submitted to Jurisdiction B or C depending on the jurisdiction you have selected. The patient's first name, last name, date of birth, and social security number are required to get a unique match.
After entering all of the required information, check the box which says "I am not a robot. It also informs you of our holiday closure schedule. Currently this feature is used exclusively for Targeted Probe and Educate TPE cases in which you have already responded to an ADR request, but our Medical Review staff needs additional information for instance, when your ADR response did not include all requested documents or information. When you receive a message, you have five business days to respond to the request; after 10 business days the message is deleted.
When a message is generated to you by CGS staff, you will receive email notification from myCGS stating that you have a new message. You cannot initiate a message yourself in myCGS, only respond to a message we have sent regarding a claim. End Users by default do not have access— DAs must specifically give End Users access to secure messaging in order for them to access the inbox. To access your inbox, select the inbox icon in the top-right corner of your screen you can access your inbox whether you have any unread messages or not.
Note that the inbox itself is jurisdiction-neutral, meaning it doesn't matter if you are currently logged into Jurisdiction B or Jurisdiction C. From the inbox, you will see the following information for each message you have:.
Click on the desired message to open it. If you hover your cursor over the message, you will also have the option of a quick reply or delete button. After selecting a message, a popup window will appear on your screen showing you the full message, as well as the following information about the message and claim in question:. Please respond to all messages sent to you within five business days. All messages are automatically deleted from myCGS 10 business days after they are sent to you.
Note that "business days" are Mondays through Fridays; holidays are not taken into account. To respond to a message in myCGS, press the Reply button. The Secure Message Form window will appear, where you can enter text and attach documents. All responses must include at least one attachment.
Enter any message you wish to include in the "Message" text box up to characters , and then press the Browse button to add your attachments.
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