Iowa, Kansas, Missouri and Nebraska Providers
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CERT is a program integrity activity that the Centers for Medicare & Medicaid Services (CMS) established to monitor the accuracy of the Medicare Fee-For-Service program.
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You will receive a request letter that includes all of the information you need to process the request. Requests for records from the CERT Contractor do not pose any HIPAA vulnerabilities and must receive prompt attention. Respond to all requests for information from within the timeframe allowed.
The CERT medical record request is sent in a light brown envelope with a return address of the CERT Operations Center in Annapolis Junction, Maryland. The envelope is clearly denoted as a Medicare Record Request with "Immediate Response Required" highlighted in red. View an image of the CERT request envelopeAdobe Portable Document Format.
Sample documentation request letters are found on the CERT Documentation Contractor (CDC) Provider Portal website. If a response is not received within 30 days of the initial letter, the CDC will send a second letter. A third letter will be sent out 60 days after the initial letter, and the final letter is sent 75 days after the initial letter.
The Claim Identification Number for identifying CERT documentation requests.
No. Medicare patients have already given authorization to release necessary medical information in order to process claims. Therefore, Medicare contractors do not need to obtain a patient's authorization to release medical information to AdvanceMed or CDC.
The CERT contractor must receive all requested documentation within 75 days of the initial request. However, it is recommended that responses are sent as soon as possible to avoid delays and further requests. Invalid or insufficient documentation will result in a denial or reduction of the claim payment.
No, the CERT contractor and WPS Medicare do not reimburse providers/suppliers or copy centers for the cost of medical record copying or mailing. Invoices for payment, or requests for collection of payment in advance should not be sent in response to Medicare record requests.
As the billing provider, it is your responsibility to obtain the medical records to support services billed to Medicare, regardless of where the records are housed. The CERT contractor should not be referred to a third party to obtain medical records.
The CERT Contractor sends follow-up record requests when a response was received to the initial request, but certain required elements of the documentation are still missing. (For example, not all dates of service submitted, missing physician order, a signature attestation is needed.) Be sure to closely review the CERT letter for details regarding what documentation is still needed.
The CERT contractor is not responsible for providing claim review results. If you have a question about your specific CERT review findings, please e-mail WPS Medicare at Medicare.CERT.Part.A@wpsic.com. Be sure to include "CERT Review Results" in the subject line and the Claim Identification Number (CID), and include your full name, address, telephone number, and Provider Transaction Access Number or Provider Identification Number (if available) in the body of the e-mail. This will assure a prompt reply to your request.
When e-mailing WPS Medicare, please do not include sensitive information. If your question pertains to a specific claim, include the Internal Control Number, not your patient's Medicare Health Insurance Claim Number.
Yes, if you disagree with the CERT review result, you have the right to appeal the decision to WPS Medicare. Redetermination requests must be made within 120 days from the date of receipt of the remittance notice or Medicare Summary Notice (MSN).
Page Last Updated: Friday, 16-Dec-2011 09:26:32 CST
