Medicare guidelines for the appeals process at
CGS apply to the appeals process for CERT
initiated denials.
additional documentation and medical records
that may be available to support the medical
need for the item(s) denied.
This CERT Claim Identifier Tool has been
designed to aid Medicare suppliers obtain the
results of their CERT review. You may search
this database by the CID number. You simply
go to the tool on the CGS website and enter the
barcoded number. It will return information as
to whether a decision has been made on your
case or not.
There are many reasons why the CERT
Contractor may identify an error on a claim
or claim line, but the most common reason is
generally related to documentation. Incomplete
or missing documentation often leads to a
recoupment of payments. Documentation is
the bane of our existence. Documentation
requirements vary with each auditor. It is very
important that you adhere to the timelines
established in the CERT audit request.
Photo: @Shutterstock.com/KWJPHOTOART
A redetermination (1st level appeal) may be
requested if you feel a CERT error was called
incorrectly. Suppliers have the same appeal rights
for CERT initiated denials as they do for denials
initiated through CGS. For more information
about the appeals process and a request form,
refer to the Appeals section of the website. If
the Redetermination is denied all other levels
of appeals are available. When requesting a
redetermination, you must be specific about
why you feel the denial was incorrect. Send
All requests for additional documentation from
the CERT contractor should be responded
to within the requested timeframe. Failure to
respond in a timely manner may result in an
error.
Once an error is identified by the CERT
contractor—your only option is an Appeal.
The CERT Coordinator may be contacted to
"FAILURE TO RESPOND
IN A TIMELY MANNER
MAY RESULT IN AN
ERROR.
ONCE AN ERROR IS
IDENTIFIED BY THE
CERT CONTRACTOR YOUR ONLY OPTION
IS AN APPEAL."
Current Pedorthics
November/December 2016
47