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Printed Date: 9/22/2015
When services are denied or down-coded by the CERT Review Contractor and an overpayment is identified, providers are entitled to file a redetermination request with Palmetto GBA.
We are seeing a growing number of appeals for which the medical records sent by providers and third-party medical billing companies are missing key components of the documentation necessary to conduct the review. Many cases involve invalid, missing or illegible signatures or no clear, written record that the service was rendered or ordered.
Prior to filing an appeal, please follow these steps:
Note: Do not resubmit the claim. The decision for denial was based upon review of medical records; therefore, claims for these services may not be resubmitted for payment consideration.
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Last Updated: 01/11/2018