The Purpose of the CERT Contractor

Published 06/06/2021

Do you know the purpose of the CERT contractor? If not, let us help you understand the role they play. 

The CERT contractor checks to see that providers are billing correctly, and contractors are paying correctly. They select and review claims, assign improper payment categories, calculate improper payment rates, and provide education to change behaviors.

You can expect to receive the following from the CERT Contractor in their request for medical records:

  • Information on the CERT process
  • Health Insurance Portability Accountability Act (HIPAA) compliance information
  • What documentation to submit
  • Timeframe for responding to the request
  • Claim information

Failure to respond to a CERT request for additional information will result in your claim being denied, a CERT error being assigned to your facility, and possible overpayment recoupment. To prevent these from occurring submit the documentation within the timeframe indicated in your CERT letter request.

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