- Introduction
- About Provider Outreach and Education
- ABN for Not Reasonable and Necessary Denials
- Appeals/Reopenings
- Assignment of Benefits
- Comprehensive Error Rate Testing
- CMS-1500 Claim Form
- Deceased Beneficiary Claims
- Electronic Data Interchange
- Evaluation and Management Services
- Fraud and Abuse
- Health Professional Shortage Area
- Hospice
- Limiting Charge
- Medical Policy Development
- Medigap
- Modifiers
- Nonphysician Practitioners
- National Provider Identifier
- Participation Program
- Payment Floor Standards
- Provider Enrollment
- Refunds and Overpayments
- Ordering and Referring Claims Information
- Return/Reject
- Standard Remittance ANSI Codes and Remittance Advice
- Appendix 1: Forms
- Appendix 2: Glossary
- Appendix 3: Place of Service Codes
Medicare Part B 101 Manual
Comprehensive Error Rate Testing
Table of Contents
Comprehensive Error Rate Testing
This information is to make providers aware they may be contacted by the CERT Contractor to participate in the CERT program. Any claims selected by the CERT contractor for review would not be a part of any audit/review conducted by National Government Services.
What Is CERT?
CMS has developed a program to calculate the national Medicare Fee-For-Service Program improper payment rate and contractor- and service-specific improper payment rate. This program is known as the CERT program. CMS receives in excess of two billion claims per year. The CERT contractor randomly selects a statistical sample of these claims for review to determine whether claims were paid properly under Medicare coverage, coding and billing rules.
The CERT Contractor is responsible for requesting, receiving and reviewing the selected claims and associated medical record documentation. The CERT Contractor requests documentation from the provider by issuing an ADR mailed to the provider's address currently on file with Medicare. The request letters are specifically tailored to the medical functions and services performed by the provider.
The statuary authority for requesting medical records and claims information fall under Section 1833(e), Title XVIII of the Social Security Act, which provides that you must supply such information as is necessary to determine whether Medicare payments are or were due under this title.
How Long Do Providers Have to Respond to a Request From the CERT Contractor?
You must respond to the request from the CERT contractor within 45 days of the date of the initial request letter to prevent the information from being overdue and/or the claim from being counted as a nonresponse error. The schedule and copies of the initial and subsequent letter requests can be found on the CERT website. Please be sure that your medical records area places a high priority on responding to requests for records from the CERT contractor. You may be contacted by NGS to encourage and remind you that documentation must be submitted.
It is important for providers to keep enrollment information current. When providers change mailing address, phone numbers, practice location, “pay to” address, ownership information, billing agency, authorized or delegated officials etc., it is important to keep Medicare informed within 30 days of the change. Please submit a change of address electronically by PECOS or mail the appropriate CMS-855 form. CMS-855 applications are available online at CMS Forms List. View ‘Change Existing Provider Enrollment Information’ for more information about making changes to Medicare enrollment information.
Correct address information will help ensure CERT documentation requests are received and allow for timely provider response.
What Happens if the Provider Fails to Send the Requested Medical Records?
Failure to comply with a request for medical records will result in a denial and recovery of payments for all services provided on the dates in question.
To send in the requested medical records for the CERT Contractor:
You will receive an ADR letter that includes claim information and a bar coded cover sheet with the CERT claim CID. Providers should:
- Photocopy each record for the requested dates of service.
- Make sure all copies are complete, legible, and contain both sides of each page, including page edges.
- Complete copies should include specific records to support the services on the claim(s) identified and include all documentation that supports medical necessity of all services billed on the claim.
- Attach the CERT bar-coded cover sheet to the corresponding photocopies and mail to the following CERT address. You may not be reimbursed for the cost of claims/medical records duplication or mailing.
CERT Documentation Center
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
- If you use a photocopy service, please ensure that the service does not invoice the CERT Contractor.
- You may submit documentation to CERT via fax at 804-261-8100. More information about additional documentation submission methods is located on the CERT website.
Questions? Contact CERT by phone at 443-663-2699 or by email at CERTprovider@empower.ai.
What Happens if an Error is Identified?
NGS receives CERT notification reports of CERT review results and responds to all identified errors (over and underpayments). Claims will be adjusted through NGS normal claim adjustment process to allow additional payment if underpaid or recoup any overpayments. Providers will be notified by letter through the normal adjustment process that will include appeal rights.
More information can be found on our Comprehensive Error Rate Testing web page.
Reviewed 10/11/2023