CERT Appeals: Providing Documentation

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: 

  • Check your Medicare remittance advice notices or educational letters to identify the reason each service was denied
  • Check with your medical records departments to see specifically what records were supplied to CERT  
  • Examine the claim and denied services. Compare them to the records sent to the CERT contractor. Make sure your corresponding entries support the date of service, procedure code, modifier, quantity billed, etc. and that the medical records support documentation and coverage requirements associated with each procedure code, diagnosis and modifier.  
  • For electronic records, make sure the 'final' signed report/note is provided. 'Unapproved' or 'interim' entries lacking valid signatures are not acceptable for medical reviews or appeals. 

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.