We Are Here To Help

Call to speak with one of our associates.

844-868-0058

We Are Here To Help

Call to speak with one of our associates.

844-868-0058

Customer Service

At CERiS, our goal is simple: to continue building strong, collaborative relationships with healthcare providers. Please complete this form and your request will be answered by an associate.

Click here if you are a participating provider for Aetna, Humana or Anthem (formerly WellPoint).

If you are a provider for Aetna, Anthem or Humana, please call them directly for assistance.

Aetna

HMO (800) 624-0756
TRD  (800) 632-3862

Anthem (formerly WellPoint)

Call the phone number indicated on the member's insurance card.

Humana

Customer Service (800) 438-7885

FAQs

Learn more about our process.

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.

Mailing Address:  

CERiS

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.

Our Purpose

At CERiS, our goal is to account for every item charged, for every hospital patient. We pride ourselves on holding our organization, our associates, and facility review process to the highest standards of integrity, objectivity and fair business practices. We understand the unique and sensitive nature of our partnerships and strive to maintain valuable relationships with our providers. Our reputation within the industry is built on fulfilling the payors fiduciary responsibility with trust and professionalism. It is with these two components we approach how we do business with you.

 

 

 

Your Partner of Choice

CERiS offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments.

Watch the Video

Your Partner of Choice

CERiS offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments.

Watch the Video

Solutions

CERiS detects and resolves payment issues for health claims. Our teams deliver savings through the prevention of improper payments. Our experience and multi-faceted processes makes CERiS the partner of choice for state agencies, commercial health, managed care organizations and third party administrators across the nation. 

Itemization Review

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Our solution performs a clinical review and comparative analysis of itemized billing statements against national and client payment standards. Our comprehensive forensic solution reviews charge utilization, appropriateness of charges, and billing behavior, to verify proper payment for claims. 

Accuracy and Validation

  • Itemization Review
  • Facility Repricing
  • Contract and Policy Applications
  • Implant Review
  • Primary Payor Cost Avoidance

The Database

Our Universal Chargemaster contains billions of charge items from over 97% of the nation's hospitals. This helps ensure accuracy and objectivity of each claim review. 

Virtual Thesaurus

The Universal Chargemaster is a virtual thesaurus of hospital billing terms, codes and abbreviations. This drives review objectivity for reference data and provides guidance for hospital billing behaviors.

See it in action

The Universal Chargemaster database matches line item descriptions and provides transparent defensibility of itemization adjustments.

Results

Our numbers speak for themselves.

Average
6%
In Network Claims Adjustments
Average
35%
Out of Network Claims Adjustments
Average
62%
Implant Claims Savings

Additional Solutions

Beyond our itemization review, CERiS offers a complete array of services for in and out of network claims. 

Facility Repricing

CERiS provides comprehensive solutions for out of network claims. We help ensure claims accuracy by providing clinical reviews, while repricing to a range of methodologies that include reasonable and customary, reference based pricing, or a mix based on your needs.

Implant Repricing

These claims are clinically reviewed and referenced to our premier database that contains all manufacturer implant device invoice data from across the country. This information is used to determine average cost and reasonable account reimbursement. 

Negotiations

Our team of professionals has extensive legal, finance and healthcare experience and utilizes our average charge and cost databases for negotiations. We leverage our strong relationships with the provider community to achieve high acceptance, while averaging 25-45% in reductions on 50% of claims processed.

Professional Claim Review

Over 80% of medical claims contain incorrectly coded charges on professional fees such as services not administered, multiple billing for the same services, unbundling of global charges and coding errors. CERiS provides a clinical review and validation of medical claims for professional charges. Our clinical experts examine the course of care to identify gaps by cross checking the care provided and the billed charges.

Testimonials

Our clients share their stories.

“Our shared goal is to treat medical providers fairly while we identify errors and duplicate charges.   CERiS has the only true itemization review that we have seen that does both."

National Carrier Client

“We have been working with CERiS for multiple years and have enjoyed great working relationships with all of their associates. They are always willing and able to work with us to develop new processes to improve our savings.”

Multi-State Carrier Client

Community

We are proud to have a community of relationships that spans Medicare/Medicaid entities, commercial health networks and insurers, third party administrators, managed care organizations and state agencies.

Our Community Government

When reviewing facility claims, we often work with our partners and entities such as the Centers for Medicare/Medicaid Services (CMS). Working closely with our community, we continue to build an industry standard to clarify billing interpretations and formulate ethical payment practices.

Payors/Employers

Our comprehensive reviews and detailed insights into facility claims make us a vital partner to large commercial insurance providers and employers who are seeking payment integrity and identifying fraud, waste and abuse (FWA). 

Medical Community

At CERiS, our decades of experience with the medical community provide the foundation needed to work with hospitals and healthcare providers. With a national footprint, we maintain a reputation of trust and professionalism in all of our services.

Careers

Work with us

Join the CERiS team and help us advance our mission of transparency, consistency and efficiency in the world of healthcare. Your contributions matter, and together, we can affect change and positive results.

Search Open Positions

Contact Us

We are here to help.

Contact us today and let us put you on the road to greater accuracy, transparency and profitability. We look forward to putting our expertise to work for you. 

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Terms of Use

Ceris Privacy Policy (Effective 1/1/2020)

Privacy Policy

Ceris Privacy Policy (Effective 1/1/2020)

 

 

Trademarks

CERiS owns a number of different trademarks and service marks, including words, logos, icons, and its website design. The following is a non-exhaustive list of CERiS marks, most of which are registered in the United States. The absence of a mark from this list does not constitute a waiver of CERiS rights to that designator of source.

 

CERIS

CERIS AND DESIGN