General CERT Information
What is Comprehensive Error Rate Testing (CERT)?
The Centers for Medicare & Medicaid Services developed the CERT program to monitor the accuracy of Medicare payments.
For additional information please visit http://www.cms.hhs.gov/CERT/ 
What outcomes are expected from the CERT program?
The CERT contractor will pull a random sample of claims processed by each Fiscal Intermediary and will validate whether the claim was paid or denied correctly. Then a claims payment determination will be processed, the sampled claim results will be entered into the Comprehensive Tracking and Reporting Database and the data will be used to calculate the following error rates:
- Paid Claims Error Rate - Dollars overpaid less dollars underpaid divided by total dollars allowed
- Services Processed Error Rate - Number of services overpaid plus number of services underpaid divided by total number of services processed
- Provider Compliance Error Rate - Dollars submitted incorrectly divided by total dollars submitted
All errors are treated equally whether they result in overpayments or underpayments to the provider of service.
WPS - Medicare will use these results to identify areas of concern and develop education materials on proper coding, documentation, and/or indications and limitations of coverage for services with high error rates.
Who is Advance Med?
AdvanceMed is the CERT Review Contractor (CRC). The Centers for Medicare & Medicaid (CMS) contracted with AdvanceMed to conduct the activities of the CERT program. As a Medicare Program Safeguard Contractor (PSC) and in accordance with the Social Security Act, AdvanceMed is authorized to request claims and medical records from providers of Medicare. Failure to comply with requests for medical records will result in recoupment of payments.
What is the CERT Documentation Contractor (CDC) reponsible for?
The CDC is responsible for requesting and receiving medical record documentation in support of the provider's claim. Below is the process they follow:
- After the CERT Review Contractor (CRC) imports the selected claims into their system, the file is transmitted to the CDC
- An initial call is made to the provider to establish a point of contact (POC), address, phone number and fax number
- The original request letter is faxed to the provider. The letter can be mailed upon request, but the preferred method is to fax the letters. When a letter is mailed, a customized envelope is used, identified with the Centers for Medicare & Medicaid Services (CMS) letterhead and marked with, "Immediate Response Required" and " Medicare Records Request"
Follow-up of the request for medical records is as follows:
- Day 0: Call 1 and send letter 1 or fax 1
- Day 30: Call 2 and send letter 2 or fax 2
- Day 45: Call 3 and send letter 3 or fax 3
- Day 60: Send letter 4
- Day 76: Score claim as an error code 99 on the Claims Status Website (at this time, any money paid will be recouped from the provider)
Provider Address Verification Web Site Available
A public web site is now available at http://www.certprovider.org and allows both Affiliated Contractors (AC's) and providers to view the system with current provider addresses and/or preferred contact information, regardless of whether or not a provider has had a claim previously sampled for CERT review. Qualified customer service representatives staff the Call Center and are available to answer AC and provider questions. In addition, the CDC will provide an imaging solution for medical record documents, which will facilitate the review process conducted by the nurses at the CRC. Providers, who are already in the database, can call change of addresses, phone numbers, fax numbers, and email addresses into the CERT Documentation Contractor Call Center Representatives (CSRs) at (301) 957-2380 or fill out the information on the web site and email the changes to us and there is no need for logins/passwords. CSRs will call providers after receiving calls/emails to verify each provider's identity. The web site will also contain educational information.
Page Last Updated: Thursday, 18-Mar-2010 05:48:29 CDT
