CERT Tip Sheet: Appeals

The Comprehensive Error Rate Testing (CERT) contractor randomly selects claims submitted to Medicare for review. Medical records are requested from the suppliers and then reviewed by health care professionals. The review is done to assure that the services provided were medically reasonable and necessary, coded accurately, and are in compliance with all Medicare policies and regulations.

When these reviews result in an adjustment to correct coding and reimbursement or deny payment, the suppliers have full appeal rights. Details on these adjusted claims can be obtained by contacting the National Government Services Provider Contact Center (PCC) at 1-866-590-6727. When contacting the PCC, please provide the following information:

CERT identification (CID) number assigned to the claim
The beneficiary’s name
Health Insurance Claim Number (HICN)
Provider Transaction Number (PTAN)
National Provider Identifier (NPI)
Last five digits of the supplier’s tax identification number
Consult with treating physicians, health care professionals, coding and billing staff, utilization review, and medical records staff about the adjusted claim. Details received from contacting the PCC should be provided to these staff members. Determine if additional information is available to support services as originally billed. Also, determine if internal process changes are required to prevent future denials of payment.

Suppliers may appeal through the normal appeal process with the local Medicare contractor. Suppliers have 120 days from the date on the initial determination notice for the first level of appeal. The medical records submitted to the CERT contractor will be available to the Medicare Appeals Department.

Note: You do not need to resubmit the original medical records sent to the CERT contractor—you only need to complete the Medicare DME Redetermination Request Form and attach any additional documentation that would help support payment of the services billed to Medicare.

All additional supporting documentation must be submitted as early in the appeals process as possible. Documentation is required to be submitted no later than the second level of the appeal process, which is the reconsideration level. For more information on submitting appeals, please see Chapter 20 of the Jurisdiction B DME MAC Supplier Manual.

Please return your appeal request and completed copy of the Medicare DME Redetermination Request form along with additional supporting documentation to:

Jurisdiction B DME MAC
National Government Services, Inc.
Redeterminations
P.O. Box 6036
Indianapolis, Indiana 46206-6036

Suppliers also have the option of submitting their redetermination requests to National Government Services via fax or through our secure internet portal called Connex.

Faxed requests will be accepted Monday through Friday during the hours of 8:00 a.m.–4:00 p.m. ET, any request received after 4:00 p.m. or on a Saturday, Sunday, federal non-workday, or legal holiday will be counted in the next business day’s workload. Suppliers should fax the Medicare Durable Medical Equipment (DME) Request for Redetermination form and any additional documentation to: 317-595-4737.

To submit a redetermination request via Connex, suppliers should login to the Connex application. Additional information on how to get signed up to begin taking advantages of the Connex application, go to www.NGSConnex.com.

If more than 120 days have passed since the CERT adjustment, you have an option to submit additional documentation directly to the CERT contractor. To do this, please obtain the CID number from the claims remarks screen, notification letter, or the PCC. Enter the CID number on your cover sheet and fax all additional documentation to the CERT contractor at 240-568-6222.