Handling Appeals Resulting from CERT-Initiated Denials

12.6 – Handling Appeals Resulting from CERT-Initiated Denials (Rev. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26) This section applies to Medicare Administrative Contractors (MACs) and Comprehensive Error Rate Testing (CERT) as indicated. The MAC shall process appeals stemming from a CERT-initiated denial. The MAC shall ensure that the appeal is handled appropriately as instructed in other CMS manuals. The MAC shall notify the CERT review contractor, using the C3HUB, when a CERT review decision is appealed. The MAC shall confirm that feedback has been completed before entering an appeal on the C3HUB. No further review shall be conducted by the CERT review contractor after the MAC has entered an appeal on the C3HUB. This includes instances in which additional documentation is received to support the claim. For instances where an appeal is dismissed or canceled, the claim is placed back into the normal CERT review process. The MAC shall not enter an appeal in the C3HUB for a claim that was canceled on or after the transaction file date. When the MAC is not able to enter an appeal on the C3HUB because the claim was canceled on or after the transaction file date, the MAC may send documentation to the CERT review contractor for further consideration. Medical records for the appealed CERT claim may be obtained by contacting the CERT appeals coordinator via the appeals page on the C3HUB. The MAC shall enter all available information for MAC feedback and appeals for CERT sampled claims by the cut-off date listed on the C3HUB calendar. Appeal determinations entered into the C3HUB by the specified due date will be reflected in the report.