Disputing a CERT Decision

12.4.3.1 – Disputing a CERT Decision (Rev.13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26) A dispute may be filed in situations in which the MAC does not agree with the final CERT review contractor decision on a claim. The MAC shall indicate the disputed claim on the C3HUB via the feedback process in accordance with this section. Using the appropriate field in the C3HUB, the MAC shall enter a detailed statement that explains the rationale for filing the dispute. Once a MAC files a dispute on a claim, they should not enter any feedback information on that claim since the claim will be removed from feedback. The CERT review contractor will conduct a re- review of the disputed claim and issue a new comment via C3HUB. If the MAC does not agree with the re-review decision or new reviewer comment, the MAC has the option to escalate the dispute to CMS via the C3HUB feedback entry. The MAC must provide a detailed rationale, via the appropriate field in the C3HUB, as to why the claim remains in dispute. The CMS dispute panel shall use Medicare coverage, coding, and billing rules in effect for the billed date of service, the medical record, CERT review contractor comments, and MAC comments/rationales to review the disputed claim. The CERT review contractor shall notify the MAC of the CMS dispute panel final decision by way of the C3HUB. The CMS dispute panel decision will appear as a new reviewer comment, and the claim will appear in the new feedback posting. Each MAC is allowed to file two disputed claims per month on or before the last day of each month. Should the MAC choose not to submit two disputes in a given month, the unused opportunity does not carry over. When an appeal has been entered for a disputed claim, the MAC shall notify the CERT review contractor immediately via the C3HUB Appeal Data Entry page to halt the dispute process.