Voluntary Pre-Claim Reviews

What You Need to Know

Although prior authorizations are not a guarantee of payment, they often give providers more confidence when billing a claim because the documentation was already reviewed and approved based on coverage criteria. For codes that do not require prior authorization, there is an increased risk of denial during a pre-payment or post-payment audit if policy criteria are not met. To help decrease some of this risk, CGS created a voluntary pre-claim review program called CGS Connect, which includes several orthotic codes not included in Medicare's prior authorization program. 

CGS Connect is a service that allows providers to voluntarily submit documentation for review and evaluation before submitting a claim to Medicare. The Medical Review clinicians not only evaluate the submitted documentation, but they also provide guidance and education back to the provider based on policy requirements. This gives the provider the opportunity to potentially correct errors before submitting the claim to CGS for payment. CGS Connect will not only improve providers' understanding of documentation requirements through one-on-one education but will also help reduce claim denials and appeals related to documentation errors.

Currently, CGS Connect is accepting submissions for the following orthotic HCPCS codes:

• Ankle Foot Orthoses: L1902, L1906, L1930, L1971, L4360, L4361, L4396, and L4397
• Knee Orthoses: L1833 and L1851
• Spinal Orthoses: L0450 - L0630, L0632 - L0636, L0638, L0640 - L0647, and L0651

Note: This program is offered by CGS, so it is only applicable for claims sent to Jurisdiction B and C. Noridian does not have a similar voluntary pre-claim review service for Jurisdictions A or D at this time.

 What this Means for You

Whether you are a new DMEPOS provider, are struggling with audits and denials, or maybe just want more personalized education on Medicare documentation requirements, the CGS Connect program can help. Before billing a claim to CGS with one of the HCPCS codes listed above, you can take advantage of this service to ensure that your documentation meets the LCD and Policy Article coverage criteria. The program will even allow you to make changes based on their feedback and then submit a subsequent request within 30 days for a second review. Like prior authorizations, this is not a guarantee of payment, but it can provide you with a higher level of confidence that your documentation meets Medicare requirements for coverage and payment before billing the claim.

To learn more about CGS Connect and how to submit your claims for voluntary review, click the link for Jurisdiction B or Jurisdiction C.