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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

CERT Appeals vs. Claim Adjustments

Novitas Solutions is aware that some Part A providers are cancelling claims and re-submitting adjusted claims when CERT (Comprehensive Error Rate Testing) alerts them via a Tech Stop or Non-Response Contact that documentation is missing or that a coding error has occurred. Because these claims have been medically reviewed by the CERT contractor, we are instructing providers to cease the practice of cancelling and adjusting claims that are selected in the CERT review process.

At the time of the Tech Stop or Non-Response Contact, the claim has been medically reviewed, but has not yet been denied. Novitas Solutions will initiate the adjustments for any necessary denials. When the CERT adjustment has been made in the FISS (Fiscal Intermediary Standard System) system, it will appear as an XXH Bill Type. Providers are encouraged to appeal denials on the XXH Bill Type as a means of submitting the corrections to these claims.

The proper appeals process should be followed to appeal CERT related claims. These are outlined on the Novitas Solutions website. Your request for redetermination must be submitted in writing and filed within 120 days from the date of your RA (Remittance Advice) or MSN (Medicare Summary Notice). There is a Medicare Part A Redetermination Request Form that we encourage providers to use in order to expedite the redetermination request.

Supporting Documentation

The following information is required when submitting an appeal request:

Request for a review; (CERT denial/reduction); 
The beneficiary name; 
The Medicare Beneficiary ID Number; 
CID number identified by CERT - (Cert Reference Number);
The specific service(s) and/or item(s) for which the redetermination is being requested;
The specific date(s) of service; 
Date of initial determination by CERT; and
The printed name and signature of the person making the request.

All evidence that supports the coverage of the service(s) being appealed must be included with the request. Remarks related to the CERT denial can be found on page 4 of the claim in FISS and should be referenced when gathering supporting evidence for the appeal.

Providers should continue the practice of submitting an adjustment claim or clerical error reopening for an incorrectly billed line item, when the provider identifies the error outside of the medical review or CERT process.

Submit Appeals to Novitas Solutions  

Part A appeal requests may be faxed to 1-888-541-3829.
Part A appeal requests may be mailed. Click here for mailing addresses.

Reference


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Last modified:  11/07/2017