What is CERT?

What is the CERT Program?
The Centers for Medicare & Medicaid Services (CMS) developed the CERT program to improve the processing and medical decision making involved with payment of Medicare claims. Under the CERT program, a random sample of claims is selected from each Medicare Contractor, and medical records are requested from the providers who submitted the claims. These records are then reviewed to determine if the claim was submitted and paid appropriately.

The CMS utilizes two contractors for the request and review of medical records; the CERT Documentation Contractor (CDC) and the CERT Review Contractor (CRC). The CDC is responsible for requesting and obtaining the medical records for the sampled claims. The CRC is responsible for reviewing the supporting documentation for compliance with Medicare coverage, medical necessity, coding, and billing rules.

Responding to CERT Requests for Records
The CDC makes an initial telephone contact with a provider to explain the CERT process and obtain a fax number (preferred) or mailing address where the medical record request can be sent. It is crucial all CERT requests be responded to timely with supporting documentation for all services billed to Medicare on the sampled claim. The documentation must also substantiate the medical necessity of the services.

If the CDC does not receive your documentation within 75 days of their initial documentation request letter, the claim is reported as a "no documentation" error to the Medicare contractor that processed the claim. If the records are not received the Medicare contractor is required to request a refund of the Medicare payment.

If there are elements missing (e.g., not all dates were submitted, missing physician order, etc.) in your documentation response, the CDC will contact you to request the missing documentation. You have 15 days from the date of their letter to submit the additional documentation. If your response is not received prior to this deadline, the claim will be reviewed based on the initial documentation received and an error will be assessed and the Medicare payment will be recouped.

Importance of Accurate Claim Payments
CERT error findings are closely monitored by the CMS, WPS Medicare, as well as the Recovery Audit Contactors (RAC), to identify issues contributing to incorrect billing. Continued error findings may result in identified problem areas being reviewed by Medicare Contractors and/or RAC contractors. Cooperation from providers in proper billing and documentation of services billed to Medicare is crucial in order to ensure accurate claim payments, and to meet CMS' error rate reduction expectations.

Page Last Updated: Wednesday, 17-Feb-2010 15:50:34 CST