Fast facts: Appealing a CERT review decision
The Comprehensive Error Rate Testing (CERT) review contractor conducts a medical review of randomly sampled post-payment claims. If the claim was billed and paid correctly, the CERT review contractor will issue a “No Error” finding. If the claim is assessed an error, the provider is entitled to pursue the established appeal process.
When a CERT claim is found to be in error, First Coast will have the claim adjusted and will process the overpayment or underpayment.
Providers will not receive a findings letter; however, a demand letter will be mailed to the billing address on file.
If you would like to obtain the CERT denial rationale for the claim, contact First Coast and submit a request via email to QuestCERT2@FCSO.com. Please do not include any protected health information (PHI) or personally identifiable information (PII), only the 7-digit claim identifier (CID) number is needed to check status or obtain the denial rationale.
If the billing provider disagrees with the CERT decision, they have 120 days from the date of the adjustment to file a level 1 appeal, also known as a redetermination, to MAC. The date of the adjustment can be found on the demand letter.
All other levels of appeal are available if timely filing occurs:
- Level 2: Reconsideration by the qualified independent contractor (QIC)
- A request must be filed within 180 days of the level 1 decision (redetermination)
- Level 3: Administrative law judge (ALJ) hearing
- A request must be filed within 60 days of the level 2 decision
- Level 4: Medicare Appeals Council review
- A request must be filed within 60 days of the level 3 decision
- Level 5: Judicial review in U.S. District Court
- A request must be filed within 60 days of the level 4 decision
Include any missing or additional documentation you may have to support the billed service(s), with the appeal.
Fill out the request for appeal thoroughly and ensure it is signed.
References