Where should appeals regarding CERT denials be sent to?
All claims denied by CERT are subject to the same appeal rights as other denials and can be appealed by the provider or beneficiary. Most appeals requests should be made with WPS-Medicare, since we processed the original claim. Please refer to our website on how to file and appeal located at http://www.wpsmedicare.com/mac/business/mr_cert.shtml. The only exception to this is for non-response and insufficient documentation denials from CERT. These will appear as reason codes 55715/55716, CERT code 21, for Insufficient Documentation, and 55677, CERT code 16, for No documentation. Additional documentation for claims that were denied due to non-response or insufficient documentation should be sent to the CERT Documentation Contractor.
All claims denied by CERT are subject to the same appeal rights as other denials and can be appealed by the provider or beneficiary. Most appeals requests should be made with WPS-Medicare, since we processed the original claim. Please refer to our website on how to file and appeal located at http://www.wpsmedicare.com The only exception to this is for non-response and insufficient documentation denials from CERT. These will appear as reason codes 55715/55716, CERT code 21, for Insufficient Documentation, and 55677, CERT code 16, for No documentation. Additional documentation for claims that were denied due to non-response or insufficient documentation should be sent to the CERT Documentation Contractor.
Related Questions
- Can we send additional information at the first level of appeals/any level of appeal? If a provider appeals, and the appeal is denied, is a letter sent explaining why?
- Who can assist me with problems related to managed care referrals, denials, and appeals?
- Where should appeals regarding CERT denials be sent to?
