What Medicare jurisdictions does CGS Administrators cover?

CGS Administrators, LLC is the Medicare Administrative Contractor for three federal jurisdictions. It processes Part A and Part B claims for providers in Kentucky and Ohio as the A/B MAC for Jurisdiction 15, home health and hospice claims for fifteen additional states and the District of Columbia, and durable medical equipment claims as the DME MAC for Jurisdiction B, covering seven Midwest states, and Jurisdiction C, covering states across the Southeast and Southwest, Puerto Rico, and the U.S. Virgin Islands.

Does CGS use Targeted Probe and Educate for DME equipment claims?

Yes. CGS runs Targeted Probe and Educate on both its Part A/B and DME MAC contracts. Suppliers and providers are selected through CGS's own data analysis, receive an additional documentation request covering 20 to 40 claims, and generally have 45 days to respond. CGS provides individualized education after each round and refers a supplier or provider who has not improved after three rounds to CMS for further action.

What happens if I do not respond to a CGS additional documentation request?

CGS does not treat silence as support for the claim. A missing or incomplete response to an additional documentation request typically results in denial of the claims under review, and a non-response during Targeted Probe and Educate counts as an error toward the round's error rate. Where CGS already paid the claim, a denial on review can become a recoupment demand for the amount paid.

CGS Administrators Medicare Audits: Part B and DME MAC Review

CGS Administrators, LLC runs Medicare claims review on two fronts for the same providers: as the Part A and Part B Medicare Administrative Contractor (MAC) for Jurisdiction 15, and as the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for two separate jurisdictions. A physician practice that bills Part B services and also supplies durable medical equipment can draw two unrelated additional documentation requests from CGS at once, each tested against a different rulebook and each able to escalate into prepayment review, extrapolation, or a Recovery Audit Contractor referral.

CGS Administrators' Medicare Contracts

CMS assigns Medicare claims processing to private contractors by jurisdiction, and CGS Administrators, LLC holds three of those contracts. As the A/B MAC for Jurisdiction 15, CGS processes Part A and Part B claims from Kentucky and Ohio providers, plus home health and hospice claims from fifteen more states and the District of Columbia. As the DME MAC for Jurisdiction B, CGS reviews equipment claims from Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin suppliers, and as the DME MAC for Jurisdiction C, from suppliers across Florida, Georgia, Texas, and twelve other states, plus Puerto Rico and the U.S. Virgin Islands. A supplier in Kentucky or Ohio sits inside two of CGS's three jurisdictions at once, the A/B MAC for Jurisdiction 15 and the DME MAC for Jurisdiction B. A companion article, Novitas Medicare Audits: What Providers in Its Jurisdictions Face, covers the contractor for two other federal jurisdictions.

Targeted Probe and Educate on Both Contracts

CGS runs Targeted Probe and Educate (TPE), the CMS medical review program, the same way on both contracts. Claims or suppliers are selected through CGS's own data analysis of billing patterns or high error rates, and CGS sends an additional documentation request (ADR) covering 20 to 40 claims; the recipient has 45 days to respond. Each round includes individualized education on the errors found. A provider or supplier who does not improve after three rounds is referred to CMS, which can order 100% prepayment review, extrapolation of the error rate across the full claims universe, or referral to a Recovery Audit Contractor (RAC).

What Each Review Actually Tests

CGS applies the same TPE process on both contracts. A Part B ADR tests whether the clinical note supports the medical necessity of the billed service and the code submitted, the same question behind Modifier 25 Audits: Separately Identifiable Service and Modifier 59 and Unbundling Allegations. A DME MAC ADR tests the supplier's file against the item's local coverage determination, its policy article, and the Standard Documentation Requirements for All Claims Submitted to DME MACs Article, covering the physician order and proof of delivery, addressed in a companion article on this site. A DME finding carries exposure a Part B finding does not. The National Provider Enrollment contractor, which replaced the National Supplier Clearinghouse as the DMEPOS enrollment contractor in November 2022, can revoke billing privileges for the same failures a CGS audit surfaces.

Responding to a CGS Documentation Request

A CGS ADR, on either contract, names the claims under review and the records needed to support them. CGS does not treat a missing response as evidence the claim was correct; incomplete or absent documentation typically results in denial and, where payment has issued, a recoupment demand. Both contracts let a provider or supplier submit records through the myCGS web portal, or by mail or fax to the address on the ADR. A CGS documentation request opens a claims review proceeding, and the response itself becomes part of the record on appeal.

A provider holding Part B and DME billing privileges in Ohio or Kentucky does not get one TPE clock. Each CGS contract runs its own three rounds, on its own documentation, with a separate escalation path to CMS.

Why early legal counsel is critical. It is critical that providers and suppliers in CGS's jurisdictions promptly retain experienced healthcare defense counsel upon receiving a TPE notice, an ADR, or any other CGS audit communication. Early legal intervention can protect the provider's or supplier's rights, help prepare a complete and accurate response to CGS's request, preserve relevant defenses, and allow counsel to communicate with CGS on the provider's or supplier's behalf. Delaying representation can affect the outcome of a matter and expose the provider or supplier to unnecessary risk, including prepayment review, extrapolation, or a Recovery Audit Contractor referral.

How Health Law Alliance can help. Health Law Alliance represents physicians and durable medical equipment suppliers nationwide in Medicare Administrative Contractor audits, including matters before CGS Administrators in both its Part B and DME MAC roles. Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience. If your practice or supply business has received a CGS TPE notice or ADR, schedule a free consultation with our Medicare audit defense attorneys to review the request and the response timeline before you reply.