Appeals Process Following Claims Correction or CERT Denial
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The Jurisdiction B DME MAC Reminds Suppliers About the Appeal Process after Claims Correction or Denial from CERT
 
The Comprehensive Error Rate Testing (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.
 
When these audits result in an adjustment to correct coding and reimbursement or deny payment, the providers have full appeal rights.  Details on the claim correction or denial can be found in the claims processing system—claims remarks screens of the adjusted claim.  If more detail is needed, you may contact Provider Contact Center. For contact information go the http://www.ngsmedicare.com/Web site, select Resources > Contact Us or Clinical Provider Outreach and Education (contact information below).
 
You may appeal through the normal appeal process.  You have 120 days from the date the denied claim was processed for the first level of review. Medical records submitted to CERT will be available to the Medicare Appeals Department. Providers only need to fill out Centers for Medicare & Medicaid Services (CMS) Form 20027 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.
 
To access the Redetermination form and additional appeal information click on or copy and paste the following links into your internet browser:
 
Redetermination Form
 
Jurisdiction B DME MAC Supplier Manual, chapter 20:
 
Questions are welcome.
Call toll free at 800-338-6101 or send an e-mail to Clinical.Education@Wellpoint.com.
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