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CGS Administrators is a Medicare Administrative Contractor for Medicare. It processes and pays claims for Medicare Parts A and B, durable medical equipment, and home health and hospice services in different parts of the country. Depending on where you live, CGS may be processing the claims your health care providers submit for your care and, importantly, deciding whether to approve or deny those claims.
- Pros and Cons
- Key Takeaways
- Company Overview
Extensive geography and services
High level of compliance with Medicare standards
No reported customer complaints
Does not offer Medicare insurance plans
- Processes claims for Medicare Parts A and B, home health and hospice, and durable medical equipment
- Covers 38 states and U.S. territories
- Operates in jurisdictions with greater than 90% compliance scores
CGS Administrators, a subsidiary of Celerian Group, is a Medicare Administrative Contractor (MAC) for the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare. Headquartered in Nashville, Tennessee, CGS serves 24 million Medicare beneficiaries and 100,000 health care professionals. CGS processes claims and payments for health care providers and suppliers who participate in the Medicare program. CGS operates as a Part A, Part B, home health and hospice, and durable medical equipment (DME) MAC. CGS does not provide any direct service to Medicare enrollees.
CGS operates in 38 states plus three territories. Its footprint for some services overlaps. CGS is the DME MAC in Jurisdiction B (which includes seven states) and C (covering 15 states, Puerto Rico, and the Virgin Islands). CGS also serves as the home health and hospice MAC (in 15 states and the District of Columbia) and a Part A and B service provider in Ohio and Kentucky.
- Parent Company Celerian Group
- Customer Service Telephone, online, myCGS portal, and CGS Medicare app
- Phone Number 866-590-6727
- Official Website www.cgsmedicare.com
- Extensive geography and services: Operates in 38 states and holds multiple Medicare Administrative Contracts (MAC).
- High level of compliance with Medicare standards: CMS’ evaluation of its administrative contracts in jurisdictions where CGS operates were all above 90%, including 95% and 97% in jurisdictions B and C, respectively.
- No reported customer complaints: A search of the Consumer Financial Protection Bureau site turns up zero complaints against CGS.
- Does not offer Medicare insurance plans: CGS is an administrative contractor that provides claims processing and service on behalf of CMS. It is not an option for people looking for Medicare insurance. It does not directly serve consumers but directs people to contact Medicare with any issues or complaints.
CGS doesn’t offer Medicare insurance plans or services for consumers. It provides support for providers who serve Medicare beneficiaries. CGS processes claims, which also means it decides whether to approve or deny claims according to Medicare rules and guidelines. Depending on the service, there are up to five levels of appeal.
CGS doesn’t sell Medicare insurance but provides administrative services on behalf of CMS.
Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC):
CGS processes claims for DME, orthotics, and prosthetics and provides service to the suppliers of those products. Suppliers submit claims to the MAC covering the geographic territory where the Medicare beneficiary lives.
Medicare Parts A and B MAC:
CGS provides customer service and processes claims for Medicare Parts A and B covered services. Providers submit Part A and B claims to the MAC covering the geography where the provider is physically located.
Home Health and Hospice MAC:
CGS processes home health and hospice claims. Providers submit home health and hospice claims to the MAC covering the geography where the provider is physically located.
Each CGS contract area has its own customer service phone number and online access.
DME MAC Jurisdiction B
Customer Service: 866-590-6727, 8 a.m. to 5 p.m. EST, Monday through Friday
Interactive voice response (IVR): 877-299-7900
DME MAC Jurisdiction C
Customer Service: 866-270-4909, 8 a.m. to 6 p.m. EST, Monday through Friday
Part A Support (Ohio/Kentucky)
Customer Service: 866-590-6703, 8 a.m. to 5 p.m. EST, Monday through Friday
Part B Support (Ohio/Kentucky)
Customer Service: 866-276-9558, 8 a.m. to 5 p.m. EST, Monday through Friday
Home Health and Hospice
Customer Service: 877-299-4500, 9 a.m. to 5:30 p.m. EST, Monday through Friday
CMS assesses each MAC based on factors such as customer satisfaction with the MAC website, provider enrollment, financial management, claims processing, appeals, and beneficiary customer service. However, CMS publishes overall average results by year, but does not publish individual contractor performance.
CGS does not directly offer customer service for Medicare enrollees, but works directly with providers and suppliers who service people on Medicare.
CMS evaluates MACs on dozens of compliance measures and publishes those results in overall reports by jurisdiction. Average compliance in Fiscal Year 2020 was 96%; compliance in the jurisdictions CGS operates in was above 90%. These CMS assessments provide oversight and accountability to the MACs.
CGS processes claims according to Medicare fee schedules for the relevant services.
Competition: CGS vs. Humana
If you’re looking for Medicare coverage, CGS is not an option; it does not offer health plans you can choose. Consider Humana, one of the largest Medicare Advantage plans with availability in 84% of U.S. counties. Humana offers many types of Medicare coverage. Humana offers Medicare plans in every state. It offers extra benefits on many plans, including dental, vision, and fitness benefits. Humana has committed to removing co-payments on Medicare Advantage telehealth visits through 2021.
|Number of States Available||38||50|
|Medicare Services||Medicare Parts A and B services, Medicare Administrative Contractor for Durable Medical Equipment in Jurisdictions B and C, and Home Health and Hospice in the Plains States and mid-Atlantic area||Medicare Advantage HMO, PPO; Private Fee-for-Service (PFFS) Plans; Medicare Advantage Prescription Drug Plans; Stand-Alone Medicare Prescription Drug Plans; Medicare Supplement Insurance (Medigap) Plans; Dual-Eligible Special Needs Plans; Chronic Condition Special Needs Plans; Limited Income Newly Eligible Transition Plans|
|Customer Service Options||Telephone, online, myCGS portal, and CGS Medicare app||Telephone, online, in-person, chat (for members)|
|AM Best Rating||N/A||A- (Excellent)|
CGS is an administrative contractor for CMS. Consumers may never even know CGS is processing their claims. Since CGS is not an insurance provider, those seeking Medicare coverage should review Medicare health plans in their area. See our picks for the best Medicare Advantage plans in 2021.
How We Reviewed Medicare Providers
Even Medicare health plans with a national presence can vary locally in their cost, quality, and customer satisfaction. To evaluate Medicare plans, we looked at health insurance industry ratings from the primary accrediting agency for health plans, NCQA, and the Medicare Star Ratings from CMS, the regulatory agency that oversees Medicare. We included the National Association of Insurance Commissioners’ complaint index, and AM Best’s financial stability ratings. We also considered information from the companies on their programs and strategies.