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Jurisdiction 1 Part B
The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests

What is the CERT Program?
The CERT Program is a federally mandated program designed 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 Medicare Administrative Contractors (MACs).

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 MAC 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) and the Multi-Carrier System (MCS)
  • 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

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What is a paid claims error rate?
The paid claims error rate is the percentage of total dollars that MACs 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.

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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.

Example of items specific to the service rendered: Skilled nursing facility (SNF) providers should include a Minimum Data Set (MDS). Include any other documentation necessary to support all services/items billed. Chiropractic providers should include the initial plan of care and any updates. Laboratory providers should include the physician’s order for laboratory services.

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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 the 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 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.

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Why is it important for the provider to confirm their current mailing address on file with the MAC?
The CERT contractor uses the same mailing address as the MAC 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 MAC to ensure all correspondence with the provider goes to the correct address. Providers should ensure that the MAC has the correct master address for their medical review specific correspondence.

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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 for Part A and CMS 855 for Part B. Providers can obtain a hardcopy CMS 855A or CMS 855 application by calling 866-931-3906 for Part A or 866-895-1520 for Part B.

An electronic version is available on Palmetto GBA’s website at www.palmettogba.com/medicare. Providers needing assistance accessing this application may contact the J1 Provider Contact Center (PCC) at 866-931-3906 for Part A or 866-895-1520 for Part B.

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:

Part A Provider Enrollment AddressesPart B Provider Enrollment Addresses

For standard mail:
J1 MAC - Palmetto GBA
P.O. Box 1508
Augusta, GA 30903-1508

For Fed Ex Packages:
J1 MAC - Palmetto GBA
2743 Perimeter Parkway
Building 200, 2nd Floor
Augusta, GA 30909

For standard mail:
J1 MAC - Palmetto GBA
Provider Enrollment
P.O. Box 1508
Augusta, GA 30903-1508

For Fed Ex Packages:
J1 MAC - Palmetto GBA
2743 Perimeter Parkway
Building 200, 2nd Floor
Augusta, GA 30909

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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 website is considered a public site and users cannot make changes to their contact information at this website. 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 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., Part A outpatient or skilled nursing facility). These checklists are helpful tools and are not all-inclusive. Please submit all documentation to support the medical necessity of the services under review.

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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 J1 medical review message line at (803) 763-4519 for Part A and Part B or the CERT Contractor at (301) 957-2380 if any 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
  • A Part A 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
  • Appeals/redeterminations of denials made by the CERT contractor should be submitted to Palmetto GBA following the normal appeal/redetermination process

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Do I have appeal or redetermination rights if my claims 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 or 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 and Part B claims. Providers can file an appeal request by completing the following:

  • A Palmetto GBA Medicare Part A or Part B Redetermination Request Form found on the Palmetto GBA’s Form Section.
  • To access this form from this Web page, select the line of business, go to the Self Service Tools and Top Links section and select Forms
  • A CMS Form 2649 found on the CMS website 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. Dates of service for which the initial determination was issued
    6. Which items and/or services 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:

For Part A:
J1 MAC – Palmetto GBA
Part A Redeterminations and Redeterminations Reopenings
P.O. Box 1131
Augusta, GA 30903-1131

For Part B:
J1 MAC - Palmetto GBA
Part B Redeterminations and Redeterminations Reopenings
P.O. Box 1252
Augusta, GA 30903-1252

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 websites:

  • Palmetto GBA website at www.palmettogba.com/medicare, select J1 Part A or J1 Part B and then click the CERT menu link listed on the left side of the J1 Part A or Part B home page

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last updated on 04/16/2013
ver 1.0.37