CERT Appeals
The Appeal Process:
Providers have the same appeal rights for CERT initiated denials as they do for denials initiated through CIGNA Government Services. All the same Medicare guidelines apply, including those regarding the 120-day time frame allowed for an appeal.
For Part B appeals, the Medicare regulation states that a party who is dissatisfied with an initial determination may request that the carrier review such determination. The request for review must not only identify the initial determination with which the party is dissatisfied, but must also meet the requirements for the contents of an appeal request outlined below.
If a fully-completed Form CMS-1964, Request for Review of Part B Medicare Claim, is not used to express disagreement with the initial determination, then the appeal request must contain the following information:
- Request for a review;
- Beneficiary name;
- Medicare health insurance claim (HIC) number;
- Name and address of provider/supplier of item/service;
- Date of initial determination;
- Date(s) of service for which the initial determination was issued (dates must be reported in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form); and which item(s) and/or service(s) are at issue in the appeal.
You may access Form CMS-1964 at http://www.cms.hhs.gov/forms/cms1964.pdf.
Supporting Documentation:
Incoming appeal requests submitted without necessary supporting documentation will be given second priority to appeal requests submitted with appropriate documentation. Consequently, determinations or decisions on appeal requests that are submitted without appropriate documentation to support the contention that the initial determination was incorrect could possibly be delayed.
Providers should be specific about what they want reviewed and why. A copy of the claim and any supporting documentation should be sent with the request. Mark your envelope to the attention of the Appeals department and clearly state in the inquiry that a review is being requested. Allow 45 days for completion of your request for a review. Do not submit second requests or check the status of your review before the 45 days have elapsed. NOTE: Some issues can be handled by telephone.
Written requests for appeal should be sent to:
Idaho Providers:
CIGNA Government Services
Attn: Appeals
P.O. Box 22990
Nashville, TN 37202
North Carolina Providers:
CIGNA Government Services
Attn: Appeals
P.O. Box 24770
Nashville, TN 37202
Tennessee Providers:
CIGNA Government Services
Attn: Appeals
P.O. Box 23950
Nashville, TN 37202
Tips for Requesting Appeals:
- A review must be requested within four months of the original claim determination (i.e., the date on the Medicare Remittance Notice). Also, as a safeguard, we ask that all telephone reviews be requested within at least three months of the original claim determination. If it is determined that the issue cannot be resolved through Telephone Review, you will still have one full month to meet the four-month time limitation for filing a written request.
- When documentation is submitted with your request, be sure the patient's name is identified on every page. The Appeals department cannot accept documentation that does not indicate the name of the patient even if the name is on previous pages of the documentation.
