CERT Appeal Results

12.6.1 – CERT Appeal Results (Rev. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26) All CERT appeals must be expedited, and data must be corrected and finalized to ensure its inclusion in the final national and contractor level calculations. • To finalize an appeal, the MAC shall enter the “Date Appeal Process Finalized”. The MAC shall enter the date for each level of appeal. • The “Appeal Recalculated Allowed Amount” is not the paid amount. The “Appeal Recalculated Allowed Amount” is the amount paid to the provider (or beneficiary) plus any deductible applied to this claim plus the co-insurance amount. • If co-insurance or a deductible was applied to a claim resulting in no payment to the provider, an entry of zero in the recalculated allowed amount results in payment error equal to the deductible or co-insurance applied. For example, if a $1,100 deductible is applied to a claim resulting in $0 claim paid amount, the allowed amount of $1,100 should be entered as the recalculated allowed amount. Payment errors are calculated by subtracting the recalculated amount from the final allowed amount. If the claim paid amount of $0 was entered as the recalculated amount a payment error of $1,100 would be calculated. • The contractor shall access the C3HUB and correct any incorrect entries.