Comprehensive Error Rate Testing (CERT) Question and Answer Fact Sheet


What is the CERT process?
The CERT process created a way for the Centers for Medicare & Medicaid Services (CMS) to look at the Medicare accuracy of claims processed by all Medicare Administrative Contractors (MACs). The CERT contractor reviews a random sample of processed claims to determine if there has been an improper payment. An improper payment may include a claim that should have been fully or partially denied or paid at a different level based on the submitted documentation provided by the billing provider. These sampled claims are not selected based on a provider number but are service specific.

Who is the CERT contractor?
There are two contractors who comprise the CERT program. The CERT Statistical Contractor (CERT SC) and the CERT Review Contractor (CERT RC). The CERT SC is administered by The Lewin Group, Inc., who designs how the claims are sampled and calculates the improper payment rates. The CERT RC is administered by NCI Information Systems, Inc. The CERT RC’s function is to request, maintain, and review the sampled medical records to determine if the claims were appropriately paid. Once the reviews are completed for a specific period, the CERT SC calculates an improper payment rate for claims that were either overpaid or underpaid in error. This is referred to as the "improper payment rate." The CERT contractors are not part of Palmetto GBA.

What is an improper payment rate?
This rate is based on dollars processed after the MAC made its payment decision on the claim. These rates include paid and denied claims. The improper payment rate is the percentage of total dollars the MACs erroneously paid or denied. This is a good indicator of how claim errors impact the Medicare trust fund.

How does the CERT process work?
The CERT process includes the random selection of processed claims for each individual MAC, requesting medical records, and reviewing the sampled records to determine if an error was made in payment. After all the sampled claims within a specific period are reviewed, an improper payment rate is determined for each MAC.

Are healthcare providers required to comply with CERT’s request for medical records?
Yes. The CERT process is a federally mandated program. Non-submission of medical records will result in a denial of all services billed on the claim.

How is compliance with CERT’s request for medical records beneficial to providers?
Compliance with the CERT process benefits the provider by ensuring the appropriate reimbursement of their claims, preventing unnecessary denials and appeals, and reflecting a positive impression of the provider industry by having a low payment error rate. Compliance with the CERT process may also prevent additional medical review of providers and/or provider industry.

How does the CERT request for medical records impact compliance with the Health Insurance Portability and Accountability Act (HIPAA)?
Providing medical records of Medicare patients to CERT is within the scope of compliance with HIPAA.

How will providers recognize CERT’s request for medical records?
The CERT request letters will be mailed to the correspondence address listed in the Provider Enrollment, Change and Ownership System (PECOS). The letter contains specific information on the CERT process, HIPAA compliance, a listing of documentation to submit, where and how to submit the documentation, timeframe for responding to the request, claim information, and an original barcoded cover sheet. When submitting medical records in response to CERT’s request, make sure the barcoded cover sheet is placed on top of the medical records. Please note that the list of documentation to submit in response to CERT’s request is not all-inclusive. The provider should respond with all documentation necessary to support the medical necessity of the services billed and to support the billed services were provided. If applicable, an authenticated or intent to order the billed services should also be submitted with the documentation. A sample of the request letters can be viewed on the CERT C3Hub under sample request letters.

What should the provider do if multiple requests for medical records are received from CERT?
Respond to each request separately. The provider may receive requests for several beneficiaries or just one. However, multiple requests on the same beneficiary and the same date of service may also be received. Even if you have already submitted the documentation once for that beneficiary, respond again. Attach the original barcoded cover sheet every time medical records are submitted. This cover sheet has a claim identification (CID) number and instructions on how to submit the documentation. A second request for the same patient and date of service should be carefully reviewed to determine if there was missing information from the first response or new information is being requested. CERT prefers to receive records via fax.

Where should the provider send their documentation?

  • Via U.S. Mail

CERT Documentation Center
1510 East Parham Road
Henrico, Virginia 23228
 

  • Via Fax to (804) 261–8100
    • Use the barcoded cover sheet as the only coversheet
    • Do not add your own cover sheet — this slows down the receipt and identification process
    •  Send a separate fax transmission for each individual claim
       
  • Via Electronic Submission of Medical Documentation (esMD)
    • Include a CID# or claim number and the barcoded cover sheet in your file transmission
    • Information on esMD can be found at www.cms.gov/esMD
       
  • Via CD
    • The images should be encrypted per HIPAA security rules
    • If encrypted, the password and CID# must be provided via email to CERTMail@nciinc.com or via fax to (804) 261–8100
    • Must contain only images in TIFF or PDF format
       
  • Via Email Attachment
    • The email attachment(s) should be encrypted per HIPAA security rules
    • If encrypted, the password and CID# must be provided via phone to 888–779–7477 or via fax to (804) 261–8100
    • Must contain only attachments in TIFF or PDF format

What should a provider do if they have a question about CERT request for documentation?
Providers should contact CERT directly with any questions regarding a CERT medical record requests at 888–779–7477. You may also email CERT at certprovider@nciinc.com. Be sure to include only the CID and do not include PHI. For questions not related to submission of records, call Palmetto GBA's Provider Contact Center (PCC).

  • Jurisdiction J (JJ): 877–567–7271
  • Jurisdiction M (JM): 855–696–0705

What is the time frame for responding to CERT’s request for medical records?
The initial letter requesting records asks providers to submit the medical records within 45 days of the initial letter date. If documentation is not received within that timeframe, the provider may receive up to three additional letters and/or phone contacts from CERT. Also, Palmetto GBA may complete a courtesy call to assist with questions and responding to the request. If CERT does not receive the records by the 75th day from the date of the initial letter, the CERT will notify Palmetto GBA to adjust the paid claim and recoup all payment for non-submission of documentation. Please see the CERT contractors letter and contact information on the CERT C3Hub.

How long does CERT have to review the medical records?
CERT samples Medicare claims during a specific Report Year. Claims selected for review will have a Universe Date (PDF), the date the claim entered the Medicare System, within the specified Report Year. The claim with the oldest Universe Date will be reviewed first. For more information about the CERT report year, visit cms.gov

If the provider has submitted their records, why is CERT asking for more information?
After CERT receives the medical records from the provider, the documentation is sent for medical review. If a pertinent piece of documentation is missing, CERT will call and/or send a letter the provider to request that missing documentation. Palmetto GBA may also call the provider to ensure the provider understands what records are needed for review to avoid an unnecessary denial of services. If it is determined there is no additional documentation to submit, the provider should notify CERT and not disregard the request. The provider should also check with their billing department to determine if the claim was billed in error. Medical records should support all services billed on a claim. Please keep in mind that medical records should not be altered. When entries related to services are not properly documented, the documentation will need to be amended, corrected, or entered after rendering the service. 

How will the provider be notified of the review decision?
If CERT disagrees with the original payment of the claim, the MAC is notified of the decision and the MAC will adjust the claim to fully or partially deny or recode the claim based on CERTs decision. Adjustments can be identified on the provider’s remittance advice. Palmetto GBA will send a Teaching and Instruction for Provider (TIP) education letter to the provider regarding the specific reason for the denial or recoding of the claim. A follow-up phone call may also be completed to ensure the provider understands why the claim was adjusted. The provider is not notified when CERT agrees with Palmetto GBA original determination.

How can I find out if the claim was in error or not?
Palmetto GBA now provides this information within eServices, our free internet-based, provider self-service portal. The application can be accessed by going to www.PalmettoGBA.com/eServices. For questions on how to use eServices and register, refer to the eServices User Manual. The CERT information is in eServices under the eReview tab and then by selecting the eAudit tab. Please be advised that this information is updated monthly.

Providers can now log onto CERT C3Hub to obtain claim review status information under the claim status search feature. This website is operated by the CERT Contractor and updated daily. Please advised that this is a public website and review results cannot be published. Providers may contact the CERT Point for Contact for Palmetto GBA for results of the CERT review. Please do not contact CERT for the review results. Refer to the Medicare Program Integrity Manual, Publication 100-08, Chapter 12 (PDF) for more information about how CERT information is disseminated to the provider community. 

May the provider appeal the CERT contractor's decision?
Yes. Follow the normal redetermination process to appeal all CERT denials. Providers are encouraged to use the optional CERT redetermination form which is available on our website and also through eServices.

Is your address current?
CERT and Palmetto GBA use the mailing address on file in the Medicare system. If the address is incorrect, the following options may be used to make corrections:

  • Visit the CMS website to obtain a CMS-855A form (PDF) to update provider enrollment information at Palmetto GBA. The CMS 855A application cannot be sent electronically. An original signature is required, so the form must be printed, signed and mailed.
  • Contact the Provider Contact Center for assistance with address changes
    • Jurisdiction J (JJ): 877–567–7271
    •  Jurisdiction M (JM): 855–696–0705

What if I just want to designate a special address for CERT to use when requesting records?

  • All initial letters requesting medical records will be sent to the address in FISS/MCS
  • After the initial request letter is sent on a specific CID, providers can designate a point of contact, address and/or phone number for future CERT correspondence related to that CID by contacting the CERT customer service center at 888–779–7477 or sending an email to certprovider@nciinc.com
  • CERT does have a Chain Address Program for providers such as a hospital chain with multiple PTANs that providers can take advantage of with CERT. Providers should contact CERT at the above number and/or email address. Please see the CERT contractors letter and contact information on the CERT C3Hub for additional information and guidance concerning this.
  • It is extremely important to keep your address updated in the Medicare systems (FISS/MCS) by completing the CMS-855A form. The form can be submitted using the paper version or via the Internet based Provider Enrollment Chain Ownership System (PECOS) online submission process. The link to the paper version is CMS-855A form (PDF) on the CMS website. For the internet-based PECOS, visit the CMS website.

For information on updating addresses with PECOS, please see MLN Matters® Article SE1617 for additional information (PDF).

For more detailed information about the CERT process, visit the following websites:





Last Updated: 01/10/2022