Appeal Rights
How do I Appeal a CERT Denial?
If you have received notification that a claim has been denied by the CERT due to non-submission of records, or insufficient documentation, and you have obtained the requested records, you should send those records to the CDC. They will determine if their review can be completed with the additional records, which may result in a revision of the error rate and a reversal of the claim denial, when appropriate.
Records can be faxed to the CERT Documentation Contractor at (804) 864-9941.
Please be sure to include the CERTs original request letter since it contains the bar code or if the request letter is not available, write the CERT Claim ID number on each page of the records.
All other denials should be appealed through WPS Medicare's Claims Appeals Department through the normal appeals process.
According to the Medicare Claims Processing Manual Chapter 29 - Appeals of Claims Decisions:
The provider may appeal an initial determination only if:
- Items or services are not covered because they are not reasonable and necessary or constitute custodial care;
- Neither the beneficiary nor the provider knew or could reasonably have been expected to know that the services were not covered; and
- The beneficiary has been found not liable for the cost of the service(s) under limitation of liability or indicates in writing that he/she does not intend to request reconsideration of the Fiscal Intermediary's (FIs) initial determination.
- If the beneficiary appeals the FIs initial determination, the provider is made a party to the appeal.
Beneficiaries are almost always considered parties to a Medicare determination, as they are entitled to appeal any determination related to their claim. The beneficiary's appeal rights are on the back of the Explanation of Medicare Benefits (EOMB), if they are in the Original Medicare Plan, or on the Medicare Summary Notice (MSN) that is mailed from a contractor that handles bills for Medicare.
Page Last Updated: Tuesday, 15-Jul-2008 10:35:50 CDT
