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April 6, 2017

How to Appeal a CERT Error

When providers disagree with a CERT decision they have the right to appeal the error by following the Medicare Redetermination process outlined on our website:

We HIGHLY recommend prior to filing the appeal that you understand what CERT found in error, for example:

  • Was your error due to missing documentation?
    • This missing documentation should be submitted with your appeal request.
  • Was your error due to a missing signature?
    • You will need to submit a valid attestation with your appeal request/or an electronic signature that was appended at the time of the service.
  • Were you missing documentation of medical necessity?
    • When filing your appeal, it is imperative to submit the office note documenting the medical necessity/reason the service was requested.

Not sure why CERT found your claim in error:

CGS faxes letters to the CERT contact on file with details of the CERT errors to assist you with your appeal, if you do not receive this letter you may do one of the following:

  • Sign up for the CGS CID Tool.
    • By using this tool you should be able to search using the CID and find the actual CERT reviewer comments.
  • Email our CERT mailbox J15CERTCID@cgsadmin.com.
    • Include only your CID number (including any patient information would be a HIPAA violation) W
    • Within 3 business days you will receive a return email with your results.
    • If you prefer a fax of your results include your SECURE fax number and contact name in the email
  • Call our CERT Coordinator, Julene Mull at 615.782.4591.
    • Be sure to have your CID number when calling.
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