Providers can help decrease the CERT error rate by sending all documentation requested to support the services on the sampled claim chosen by the CERT contractor. This will help decrease potential filing of appeals and ensure the accuracy of the CERT error rate.

Submission of documentation to CERT is NOT a violation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Documentation can be submitted to the CERT Documentation Contractor (CDC) via fax at 240-568-6222. Please include the barcoded cover sheet with the CID# for claim identification. If the barcode sheet is not available please include the CERT Identification Number ( CID#) on the cover sheet. If the records are too large to fax, or you would prefer to mail them, they can be mailed to:

CERT Documentation Contractor

Attn: CID# XXXXXX

9090 Junction Drive Suite 9

Annapolis Junction, MD 20701

The CDC Customer Service Call Center can be contacted for any questions at 301-957-2380 or toll-free at 888-779-7477.

It is important to verify all of the following before sending records:

• Correct beneficiary and HIC number
• Correct service/treatment billed
• Correct dates of service
• Units billed match services rendered
• Correct HCPCS code
• Correct charges billed
• Legible documentation

It is the provider/supplier’s responsibility to contact the third party for the documentation requested if unavailable at their site. If the records continue to be unavailable, it is the provider/ supplier’s obligation to contact the CERT Documentation Center to notify them that you are unable to obtain or provide them with the documentation requested.

Remember, if you bill the services, the documentation must support that the services were performed and medically necessary.

It is very important to submit records. If they are not submitted, the claim will be denied and the monies will be recouped.

CERT determinations have appeal rights. If you have a denial you may send late or additional documentation to the CERT contractor rather than submitting an appeal. CERT appeals may also go through the normal contractor appeal process.

Additional documentation may also be requested and will be indicated in the CERT Documentation request letter. Please send all documentation requested in a timely manner. Documentation suggestions are listed below to assist providers when sending documentation for review.

Evaluation and Management (E/M) Services

• Provider progress notes and orders
• All orders for labs/tests/results, etc.
• Documentation to support all additional services billed on claim
• Consultation order/report sent to referring M.D.
• Nurse’s notes

Durable Medical Equipment (DME) Suppliers

The type of documentation the supplier should provide depends on the equipment and/or supplies ordered. When submitting documentation, you may reference the local coverage determination (LCD) that pertains to your service for the Medicare rules and regulations on what is needed to support medical necessity. Some typical components include:

• Written physician order (verbal orders must have a written order on the premises prior to billing Medicare)
• Certificate of Medical Necessity (CMN) when applicable
• Proof of delivery
• Advanced Determination of Medicare Coverage (ADMC)

Critical Access Hospital (CAH) and OPPS

Labs and Diagnostics

• Orders with diagnoses
• Results/reports

Clinic/ER visits

• Itemized bill
• History and physical
• M.D. orders
• Progress notes (be sure E/M billing code equal to level of services rendered (guidelines as in Part B))
• Medication administration records
• Treatment/procedure notes

End-Stage Renal Disease (ESRD)

• Beneficiary election of ESRD method
• History and physical
• Medication administration records (MAR)
• Hemoglobin and Hematocrit
• Treatment records
• Physician orders
• Progress notes
• Itemized bills
• Diagnostic test results

Skilled Nursing Facility (SNF)

• Hospital discharge summary
• Itemized bill
• Minimum Data Sheet (MDS)
• Progress notes for all disciplinary (especially physician, therapies and nursing)
• Therapy treatment plans (M.D. certified)
• Therapy logs (include minutes of timed modalities)
• Lab results
• All documentation above for a related billing period and look back periods

Hospice

• Hospice election form
• Hospital discharge summary
• History and physical
• Itemized bill with revenue codes
• Six-month terminal illness Certification/recertification
• M.D. orders for services billed
• Treatment plan
• Progress notes physician and non-physician
• Medication administration records

Home Health

• Initial Intake Assessment including OASIS
• Hard copy of the applicable OASIS related to the billing period
• M.D. orders
• Certification of home bound status
• Initial therapy evaluation/reevaluations
• Plan of care
• Progress notes/treatment records from all applicable disciplines
• All diagnostic test results

Therapies – PT, OT, SLT, Respiratory and Psychiatric

• Initial/reevaluations
• Treatment plan/plan of care (M.D. certified)
• Treatment logs/notes (include treatment time to support units billed)
• Discharge note if patient discharged before submission of record

Inpatient Rehabilitation Facilities (IRF)

• Diagnostic test results/reports
• History and physical
• Hospital discharge summary
• Pre-admission screening/therapy assessment/physical medicine rehabilitation (PMR) consult prior to admission to IRF
• Itemized bill with revenue codes
• Medication administration records
• Physician orders for dates of service billed
• Physician/non-physician progress notes including consultations
• Procedure notes/treatment records (including minutes for therapy)
• Treatment plan/plan of care M.D. certified
• Initial evaluation/reevaluation including evaluation for therapy
• Discharge note/report from IRF stay when patient had been discharged
• IRF PAI – especially medical and discharge information sections