The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests (Revised February 2009)
What is the CERT Program?
The CERT Program is a federally mandated program set in place to monitor and improve accuracy of Medicare payments. This program created a way for the Centers for Medicare & Medicaid Services (CMS) to look at the Paid Claim Error Rate and provider compliance for all fiscal intermediaries (FIs).
Who administers the CERT Program?
The CERT program has two contractors. These contractors are independent companies awarded a contract by CMS to conduct the CERT process. The CERT contractors are not part of Palmetto GBA. The program has two components:
- The CERT Documentation Contractor (CDC) requests and receives medical records.
- The CERT Review Contractor (CRC) reviews the submitted records and notifies the FI of the claim review decision.
The CERT Contractors:
- Randomly select claims processed by a Medicare contractor for CERT medical review;
- Request copies of medical records from the provider using the medical review addresses on file in the Fiscal Intermediary Shared System (FISS);
- Perform the medical review of the claims selected;
- Determine accuracy of claim payment;
- Determine recoupment of monies, if necessary;
- Calculate the paid claim error rate; and
- Report this information to CMS.
What is a paid claims error rate?
The paid claims error rate is the percentage of total dollars that FIs erroneously paid or denied for claims and is a good indicator of how claim errors impact the Medicare trust fund. This rate is based on dollars processed after the FI has made its payment decision on the claim and includes paid and denied claims.
How will CMS use this information?
CMS uses the CERT contractor’s findings to determine underlying reasons for errors in claim payments or denials, and to implement appropriate provider corrective actions aimed toward improvements in the accuracy of claim submissions and systems of claims processing.
What is included in a CERT Request?
The CERT request is mailed in a dark tan envelope and includes the following:
- “Immediate Response Required” printed in red on the envelope, “Medicare Response Required” printed in black on the envelope;
- Information about the CERT process;
- List of information to submit;
- Where to mail or fax the documentation;
- Time frame for responding;
- Contact name and number to contact CERT with questions or comments;
- Claim information;
- Bar-coded page;
- CERT claim ID number (CID);
- Health Insurance Portability and Accountability Act (HIPAA) compliance.
Note: HIPAA does not preclude providers from sending requested medical records or documentation to a Medicare contractor. Medicare beneficiaries, upon enrollment in the program, are informed of Medicare’s use of their personal health information to carry out health care operations.
The list of items requested in the CERT letter is not all-inclusive. Providers should send all information necessary to support coverage and medical necessity of the services billed.
Examples of items specific to the service rendered: Home health providers should include the Outcome and Assessment Information Set (OASIS) to support the HIPPS code billed. Hospice providers should include a signed Notice of Election (NOE). Skilled Nursing Facility (SNF) providers should include a Minimum Data Set (MDS). Include any other documentation necessary to support all services/items billed.
How does compliance with the CERT Program benefit the provider?
- Ensures the appropriate reimbursement of the provider’s claims;
- Prevents unnecessary denials and the need to request an appeal/redetermination;
- Reflects a positive impression of a provider industry by having a low error rate;
- May prevent additional medical review of the provider and their industry;
- Helps support the solvency of the Medicare Program.
What should the provider do when a request for records is received from the CERT contractor?
- Be alert to these requests from the CERT Contractor.
- Educate agency staff who receive the mail, on how to identify CERT letters and where to forward the request within the agency.
- Separate each response and paper clip or rubber band the ORIGINAL bar-coded sheet to each individual set of records.
- Remember to update the provider contact information with the CERT contractor so you may be contacted, if necessary.
- If responding to multiple requests on the same beneficiary for various dates of service, respond to each request separately.
- Return the ORIGINAL bar-coded sheet – Please do not send a photocopy.
- Respond to the CERT request within 75 days.
- The CERT contractor prefers that the information be faxed to their office. Instructions on how to do this are included in the multi-page letter.
Note: If records are faxed to the CERT contractor, the CERT contractor will send a fax confirmation of receipt of records to the provider. The confirmation letter will include the CID number only for identification purposes. If a confirmation letter is not received, the provider may call the CERT contractor to verify the receipt of records.
- If the provider chooses to mail the CERT response, it is recommended that the CERT response be mailed by return receipt mail.
- Request and include needed documentation from third parties if applicable.
- Fax or mail the requested information to the number or address listed in the CERT contractor letter.
Note: It is the provider’s responsibility to make requested medical records available to the CERT contractor even if they reside with a third party.
Why is it important for the provider to confirm their current mailing address on file with the fiscal intermediary?
The CERT contractor uses the same mailing address as the FI for medical review specific correspondence. Not all providers will receive requests from the CERT contractor; however, it is important that the provider has the correct address on file with the FI to ensure all correspondence with the provider goes to the correct address. Providers should ensure that the FI has the correct Master Address for their medical review specific correspondence.
How can providers change their medical review correspondence address on file with Palmetto GBA?
If a provider needs to change their medical review correspondence address with Palmetto GBA, the provider must complete a CMS 855A application. Providers can obtain a hardcopy CMS 855A application by calling (803) 382-6167.
An electronic version is available on CMS’s Web site at www.cms.hhs.gov/cmsforms/downloads/cms855a.pdf.
Providers needing assistance accessing this application may contact the Provider Contact Center at (877) 567-9249 for South Carolina and North Carolina Part A. Home health and hospice providers should call (866) 801-5301.
Providers must also include their provider number and National Provider Identification (NPI) to make changes to their provider information.
Note: The application cannot be submitted electronically. An original signature is required, so the form must be printed, signed and mailed to one the following Provider Enrollment addresses:
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Part A Provider Enrollment Addresses
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Part B Provider Enrollment Addresses
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For standard mail:
Palmetto GBA
Part A Provider Enrollment
Mail Code AG-331
PO Box 100144
Columbia, SC 29202-3144
For Fed Ex Packages:
Palmetto GBA
Part A Provider Enrollment
Mail Code AG-331
2300 Springdale Drive, Bldg 1
Camden, SC 29020 |
For standard mail:
Palmetto GBA
Part B Provider Enrollment
Mail Code AG-310
PO Box 100190
Columbia, SC 29202-3190
For Fed Ex Packages:
Palmetto GBA
Part B Provider Enrollment
Mail Code AG-310
2300 Springdale Drive, Bldg 1
Camden, SC 29020 |
How can the provider change their medical review correspondence address on file with the CERT contractor?
The provider mailing address and phone number on file with the CERT contractor may be viewed at www.certprovider.org/ for accuracy. This Web site is considered a public site and users cannot make changes to their contact information at this Web site. Providers may update the mailing address and phone number by contacting the CERT contractors’ customer service call centers at (301) 957-2380.
What should providers avoid when responding to CERT requests?
- Delaying their response to the request;
- Stapling the ORIGINAL bar-coded sheet to the records;
- Submitting a photocopy of the bar-coded sheet;
- Punching holes in the records as this may obscure valuable information.
What information should be submitted by the provider in response to the CERT Contractor request for records?
Checklists for all provider benefit types were created by the Medical Review Department at Palmetto GBA. To view these checklists, select the PDF documents below. Refer to the CERT checklist depending on the type of claim, e.g. Home Health, Part A Outpatient, Hospice, or Skilled Nursing Facility (SNF). These checklists are helpful tools and are not all-inclusive. Please submit all documentation to support the medical necessity of the services under review.
What happens if the provider does not respond to the CERT Contractor request for records?
Providers have 75 days to respond with the requested information, even if the records reside with a third party. Non-submission of documentation or incomplete documentation will result in a reduction or denial of payment. Providers with documentation that has been logged with the CERT contractor will not receive continued follow up calls and letters unless requested documentation is missing.
- Call the Palmetto GBA Medical Review message line at 1-803-763-7491 or the CERT contractor at 1-301-957-2380 if assistance is needed.
- The provider must have the CID number when calling the CERT contractor about a request. Please include the CID number when leaving inquiries on the Medical Review message line.
What is the outcome of CERT review?
The CERT contractor notifies Palmetto GBA of their determination only when there has been a change in the original claim decision.
- Palmetto GBA will adjust the claim.
- The adjusted claim can be identified by an XXH type of bill on the remittance advice.
- The “H” represents a CMS denial decision.
- CERT denials will appear on the provider’s remittance advice when the CERT contractor denies some or all of the claims or lines reviewed.
- Palmetto GBA will send an educational CERT TIP (Teaching and Instruction for Providers) Letter to explain the reason the claim was adjusted.
Note: TIP letters are for educational purposes only and are not denial notifications for appeals/redeterminations.
- Appeals/redeterminations of denials made by the CERT contractor should be submitted to Palmetto GBA following the normal appeal/redetermination process.
Do I have appeal/redetermination rights if my claim(s) is/are denied by the CERT contractor?
When the provider has claims denied by the CERT contractor, a request for an appeal/redetermination may be submitted to Palmetto GBA following the normal appeal/redetermination process. The time limit for filing a request for a redetermination is 120 days from the date of the remittance advice for all Part A lines of business. Providers can file an appeal request by completing the following:
- A CMS Form 2649 found on the CMS Web site, or
- A letter including the following information:
1. Beneficiary name;
2. Medicare health insurance claim number (HICN);
3. Name and address of provider who administered the item and/or service;
4. Date of initial determination from the remittance advice;
5. Date(s) of service for which the initial determination was issued;
6. Which item(s), and/or service(s) are being appealed;
7. A statement requesting an appeal or redetermination, i.e. “Please accept this request for a redetermination of the services [indicate services] denied for [dates], for beneficiary [name], for HICN [Medicare #]”;
8. An agency representative must sign the request.
- Mail the request for an appeal or redetermination to the following:
Palmetto GBA
Medicare Part A Appeals Department
Mail Code: AG-630
P.O. Box 100238
Columbia, SC 29202-3238
General questions regarding the CERT initiative may be directed to CERT Customer Service Call Centers at (301) 957-2380. Additional information about the CERT program is accessible from the following Web sites: