Under the Comprehensive Error Rate Testing (CERT) Program, an independent contractor (AdvanceMed of Richmond Virginia) will select a random sample of claims processed by each Medicare contractor. AdvanceMed's medical review staff (to include nurses, physicians, and other qualified healthcare practitioners) will then verify that contractor decisions regarding the claims were accurate and based on sound policy. CMS will use the AdvanceMed findings to determine underlying reasons for errors in claims payments or denials, and to implement appropriate corrective actions aimed toward improvements in the accuracy of claims and systems of claims processing.
Providers of the sampled claims will be asked during the course of the AdvanceMed review to provide additional information (e.g., medical records, diagnostic test results, home health progress notes, physical therapy notes, etc.) for AdvanceMed's staff to verify services billed were medically necessary. If contacted, you will be provided with the details regarding the necessary information. General questions regarding the CERT initiative may be directed to AdvanceMed's Customer Service Line at 1-804-864-9940. Additional information about the CERT program can be found at www.cms.gov/cert.
Request for information will be sent by mail and printed on brightly colored paper with detailed claim information. The request needs to be returned by mail within 45 days of request date along with appropriate documentation to:
CERT Operation Center
Attn: Disposition Department - Distribution
1530 E Parham Road
Richmond, VA 23228
Or fax to: 804-264-3268.
Participating in the CERT program will ensure the carrier is processing claims correctly and consistently.
(Not submitting documentation will result in a recoupment of paid claims.) Failure to send the requested information may result in a referral to the Medicare contractor fraud unit and to the Office of Inspector General (OIG).