What is the process for Appeals?
CERiS provides an appeal process for all claims on which their review has been utilized. Once an appeal is received, either by post mail or fax, it is logged and submitted to an Appeals Representative for review. The Appeal Representative will review all of the information and documentation submitted with the appeal. If the Appeal Representative determines that the documentation requires the additional review of a medical review professional, the file will be resubmitted to our Medical Review Department for determination.
Once a determination has been made on the file, the Appeals Representative will generate a response with the corresponding documentation to be faxed to the appeal contact. Escalation of the appeal is not solely based upon the request of the provider, but is determined based upon the Appeal Representative’s research of the original determination, as well as, their review of the correspondence and documentation submitted by the provider and/or the provider’s representative.
How are Appeals submitted to CERiS?
An appeal can be submitted in writing by post mail or fax. When submitting your appeal, please indicate the charge or charges that you are disputing with supporting documentation for our appeals staff to review. Please also include a contact name, phone number and fax number to whom the appeal response will be sent.
5128 Apache Plume Road
Forth Worth, TX 76109
Fax: (866) 464-0905
Attention: Appeals Department
What are the CERiS reductions based upon?
CERiS utilizes many national billing guidelines and standards during its review of claims for payment. Some of the resources utilized by CERiS include, but not limited to:
- US Code
- The Social Security Act
- Code of Federal Regulations (CFR)
- CMS Publications, including: Benefit Policy; Basic Coverage Rules (Pub. 100-02); National Coverage Determinations (Pub. 100-03); Claims Processing (Pub. 100-04); State Operations Manual (Pub. 100-07); Program Integrity (Pub. 100-08); One-Time Special Notification (Pub. 100-20); Managed Care (Pub. 100-16); Intermediary (Pub. 13); Carrier (Pub. 14); Provider Reimbursement (Pub. 15); Hospital (Pub. 10); CMS Transmittals ; Medical Learning Network (MLN) Matters; Medical Learning Network (MLN) Matters – Special Editions
- Office of Inspector General (OIG) Publications
- National Coverage Determinations
- Local Coverage Determinations
- Medicaid Publications
- Medicare Administrative Contractor (MAC) Publications
- Fiscal Intermediary (FI) Publications
- Provider Reimbursement Review Board (PRRB) Publications/Opinions
- Healthcare Payor Policy
- Information regarding generally accepted claims/billing/payment practices
- National Uniform Billing Committee (NUBC) Publications
Why is CERiS requesting an Itemized Bill?
As an agent of the payor(s) authorized representative, CERiS has been contracted to review the charges billed by the provider for the services. As such, additional documentation is required to review the services rendered and provide a recommendation to the payor(s) authorized representative accordingly.
Does CERiS review for medical necessity?
No. CERiS is not reviewing for medical necessity.
Does CERiS issue any payments on the claim or perform any recoupments?
No. CERiS does not issue any payments or handle any recoupments on any of the claims reviewed.
Does a nurse or medical professional actually review the claim?
We do have a team of medical professionals, including Registered Nurses, Certified Surgical Technicians and Professional Medical Coders, with varying backgrounds and specialties, who will review the itemized charges submitted by the provider for payment.
Is the CERiS review an audit?
No. The review is not a traditional audit and is more of a claim edit. We are not reviewing the medical charges against the medical records, but rather, we are simply looking at the charges billed against national billing standards, removing any charges that may result in duplicate payment as the result of a billing error, duplicate charge, etc.