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Comprehensive Error Rate Testing

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Appeals Process after Claims Correction or Denial

CERT Process

The CERT contractor randomly selects claims submitted to Medicare. Medical records are requested from the providers and then reviewed by health care professionals. The review is done to assure that the services provided were medically reasonable and necessary and coded and billed accurately according to Medicare policies and regulations.

Appeal Rights

When these audits result in an adjustment to correct coding and reimbursement or deny payment, the providers have full appeal rights.

Notifications and Details of Denials:

  • Denial notification is received on remits.
  • Details on the claim correction or denial can be found in the claims processing system on the claims remarks screen of the adjusted claim.
  • On our website, the “Denial Reason Finder” tool also provides description from CERT reviewers describing reason for denial.
  • Letter requesting overpayment is then mailed to providers.
  • Subsequently, monthly letters are mailed to providers with additional details describing reason for denial and how to appeal.

For questions:

If more detail is needed:

  • You may contact the National Government Services PCC. To obtain PCC contact information for your line of business and region, please access the Contact Us link on our website.
  • You may also contact the CERT Coordinator; obtain contact information via CERT letter and PCC.

Appeal Process

You may appeal through the normal appeal process.

  • You have 120 days from the date the denied claim was processed date on your remittance for the first level of review.
  • Medical records submitted to CERT will be forwarded to the Medicare Appeals Department.
  • Providers only need to complete the CMS-20027 form and attach any additional documentation that would help support payment of the services billed to Medicare.
  • Consult with treating physicians, health care professionals, coding and billing staff, utilization review, and medical records staff. Provide details of CERT audit results and determine if additional information is available to support payment.
  • Also, determine if corrective action is needed to prevent future denials of payment.
  • You can access a copy of the CMS-20027 form on the CMS website.
  • Electronic options to appeal are available via NGSConnex and esMD.
  • Details of how to appeal with electronic or mailing option is available on our website under the “Claims and Appeals” tab.
Appeals Process after Claims Correction or Denial
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