What is the Comprehensive Error Rate Testing (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 Palmetto GBA.
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 Medicare Administrative Contractor (MAC) of the claim review decision
- The CERT Contractors:
- Randomly select claims processed by a Medicare contractor for CERT medical review
- 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
- Report this information to CMS
What is a paid claims error rate?
The paid claims error rate is the percentage of total dollars that Medicare contractor 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 MAC 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. Here is an example of what the CERT envelope will look like.
A letter will be included in the envelope outlining the information needed. Click here to review sample CERT letters. Please note there may be a total of five letters that you will receive from the CERT contractor, please review each letter.
The letter will include 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.
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
- Refer to the list of items included in the CERT letter when responding
Note: This list is not all-inclusive. Send all documentation to support services and/or items billed.
- Place the bar-coded cover sheet in front of the documentation when submitting records to the CERT contractor
- 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.
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 CERT Provider website for accuracy. This website is considered a public site and users may download a form to submit changes to their contact information through email or providers may update the mailing address and phone number by contacting the CERT contractors’ customer service call centers at 888-779-7477.
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. 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 Provider Contact Center (PCC) or call the CERT contractor at (301) 957-2380 (or) toll free 888-779-7477 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
- For a Part A 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 Teaching and Instruction for Providers (TIP) 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 lines of business.
Additional information about the CERT program is accessible from the following websites:
The CDC call center operates between the hours of 8 a.m. to 6 p.m. ET, and their phone number is (301) 957-2380 (or) toll-free 888-779-7477.