Comprehensive Error Rate Testing (CERT) FAQs

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Comprehensive Error Rate Testing (CERT) Overview

  1. What is the purpose of the Medicare Comprehensive Error Rate Testing (CERT) program?
  2. Who are the CERT Contractor(s)?

CERT Medical Record Requests and Responses

  1. What happens if I am selected for a CERT review?
  2. What do the medical record request envelopes form the CERT contractor look like?
  3. What do the letters from the CERT contractor look like?
  4. What is the CID that is mentioned in the letter?
  5. Do I need to have the beneficiary's authorization to release information for a CERT review?
  6. How long do I have to respond to a documentation request?
  7. Does the CERT contractor reimburse for the cost of copying and mailing medical records?
  8. What if the requested documentation is located at another facility (ex. hospital, nursing home, referring physician's office)?
  9. I sent records to the CERT Contractor, why am I getting a follow-up request for additional documentation?

CERT Review Results and Appeals

  1. How do I get the results of my CERT claim review?
  2. Can I appeal a claim reduced or denied as a result of a CERT review?
  3. I provided a complete blood count (CBC) with differential for a Medicare patient. The CERT contractor recoded my claim to a CBC without differential. Why?
  4. What does Medicare do with Comprehensive Error Rate Testing (CERT) error findings?

Comprehensive Error Rate Testing (CERT) Overview

  1. 1. What is the purpose of the Medicare Comprehensive Error Rate Testing (CERT) program?

    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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  2. Who are the CERT Contractor(s)?

    Company Responsible for Contact Information
    Livanta - CERT Documentation Contractor Obtaining the CERT submitted documentation from providers 9090 Junction Drive, Suite 9
    Annapolis Junction, MD 20701
    Phone: (888) 779-7477 or (301) 957-2380
    Fax: (240) 568-6222
    AdvanceMed - CERT Review Contractor Reviewing the CERT submitted documentation forwarded by Livanta 1530 E. Parham Road
    Richmond, Virginia 23228
    Phone: (804) 264-1778

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CERT Medical Record Requests and Responses

  1. What happens if I am selected for a CERT review?

    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.

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  2. What do the medical record request envelopes from the CERT contractor look like?

    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.

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  3. What do the letters from the CERT contractor look like?

    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.

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  4. What is the CID that is mentioned in the letter?

    The Claim Identification Number for identifying CERT documentation requests.

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  5. Do I need to have the beneficiary's authorization to release information for a CERT review?

    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.

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  6. How long do I have to respond to a documentation request?

    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.

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  7. Does the CERT contractor reimburse for the cost of copying and mailing medical records?

    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.

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  8. What if the requested documentation is located at another facility (ex. hospital, nursing home, referring physician's office)?

    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.

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  9. I sent records to the CERT Contractor, why am I getting a follow-up request for additional documentation?

    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.

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CERT Review Results and Appeals

  1. How do I get the results of my CERT claim review?

    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 medicareadmin@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.

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  2. Can I appeal a claim reduced or denied as a result of a CERT review?

    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).

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  3. I provided a complete blood count (CBC) with differential for a Medicare patient. The CERT contractor recoded my claim to a CBC without differential. Why?

    Clinical lab services do not require a signed physician order as part of the documentation, but they do require an order or requisition for the service. In addition, the order should be clear as to what is ordered. If there is no signed order, a progress note documenting the intent of that specific test be performed should be submitted. In most of our recent error findings for a complete blood count with differential, the physician's order showed only a complete blood count. If the order does not show the medical necessity of the service, the lab may request additional documentation from the physician's office to support the medical necessity of the service.

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  4. What does Medicare do with Comprehensive Error Rate Testing (CERT) error findings?

    The Comprehensive Error Rate Testing (CERT) Program is designed to measure improper payments in the Medicare Fee-for-Service Program, as required by the Improper Payments Information Act of 2002. The goal of Medicare is to "pay claims right the first time." In an effort to reach this important Centers for Medicare & Medicaid Services (CMS) and WPS Medicare goal, WPS Medicare continues to publish targeted education on our CERT web pages. This includes identification of actual errors, how providers, coders, and billers can take action to avoid future errors, and resources to assist in the preparation and submission of accurate claims.

    In ongoing efforts to identify issues contributing to incorrect billing, CMS, WPS Medicare, and other CMS contractors, including Recovery Audit Contractors, closely monitor CERT error findings. Future review by these contractors of claims associated with identified problems may occur. 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.

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Page Last Updated: Friday, 16-Dec-2011 09:31:47 CST