How does the CERT process work?

The CERT Review Contractor (CRC) selects a stratified random sample of Medicare FFS claims for review based on claim type. The CRC then requests documentation to support that service from the provider or supplier who submitted each of the claims in the sample. Once the documentation is received it is reviewed by independent medical reviewers to determine if the claim was paid properly by the MAC, under Medicare coverage, coding, and billing guidelines. If the documentation does not support that those guidelines were met, the claim is counted as a total or a partial improper payment. The error is then categorized into one of the following categories: (1) No Documentation, (2) Insufficient Documentation, (3) Medical Necessity, (4) Incorrect Coding, or (5) Other. The MAC is then responsible for collecting the funds that were incorrectly paid to the provider.

Contact Railroad Medicare

Email Railroad Medicare

Contact a specific Railroad Medicare department

Provider Contact Center: 888-355-9165

IVR: 877-288-7600

TTY: 877-715-6397

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