Please Note: There is no Medicare information on our corporate website. Please select a specific contract in the 'Search Within' box for Medicare related information.
© 2018 Palmetto GBA, LLC
We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.
Printed Date: 9/22/2015
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 who designs how the claims are sampled and calculates the improper payment rates. The CERT RC is administered by AdvanceMed, an NCI Company. 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 time 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 'paid claims error rate'. The CERT contractors are not part of Palmetto GBA.
What is a 'paid claims error' 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 paid claims error 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 time period are reviewed, a paid claims error rate is determined for each MAC.
Are healthcare providers required to comply with the CERT RC'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 the CERT RC’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 RC's request for medical records impact compliance with the Health Insurance Portability and Accountability Act (HIPAA)?
Providing medical records of Medicare patients to the CERT RC is within the scope of compliance with HIPAA.
How will providers recognize a CERT RC’s request for medical records?
The CERT request letters will either be mailed or faxed. 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 the CERT RC'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 the CERT RC's request is not all-inclusive. The provider should respond with all documentation necessary to support the medical necessity of the services provided.
What should the provider do if multiple requests for medical records are received from the CERT RC?
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. The CERT RC prefers to receive records via fax, encrypted CD or esMD.
Where should the provider send their documentation?
Via Postal Mail to:
CERT Documentation Center
1510 East Parham Road
Henrico, Virginia 23228
Via Postal Mail to:
CERT Documentation Center
1510 East Parham Road
Henrico, Virginia 23228
What should a provider do if they have a question about the CERT RC's request for documentation?
Providers should contact the CERT RC directly with any questions regarding a CERT medical record requests at 443-663-2699 or toll free at 888-779-7477. You may also email the CERT RC at email@example.com. However, 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) at 855-696-0705.
What is the time frame for responding to the CERT RC'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 the CERT RC. Also, Palmetto GBA may complete a courtesy call to assist with questions and responding to the request. If the CERT RC does not receive the records by the 75th day from the date of the initial letter, the CERT RC will notify Palmetto GBA to adjust the paid claim and recoup all payment for non-submission of documentation.
How long does the CERT RC have to review the medical records?
There is no set time frame for the medical review by the CERT RC.
The provider has submitted their records so why is the CERT RC asking for more information?
After the CERT RC receives the medical records from the provider, the documentation is sent for medical review. If a pertinent piece of documentation is missing, the CERT RC will send a letter and/or call 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 in order to avoid an unnecessary denial of services. If the provider determines they do not have the missing documentation, notify the CERT RC. Keep in mind that signed medical records cannot be altered.
How will the provider be notified of the review decision?
The provider is not notified by the CERT RC when they agree with the original determination. If the CERT RC 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 the CERT RC's 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.
How can I find out if the claim was in error or not?
Palmetto GBA now has this information on their website under 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 located in eServices under the eReview tab and then by selecting the eAudit tab.
May the provider appeal the CERT contractor's decision?
Yes. Follow the normal redetermination process to appeal all CERT RC's denials. Providers are encouraged to use the optional CERT redetermination form which is available on our website at www.palmettogba.com and also through eServices.
Is your address current?
The CERT RC 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:
What if I just want to designate a special address for CERT to use when requesting records?
For more detailed information about the CERT process, visit the following websites:
We value your opinion and want to provide the highest-quality and most relevant Medicare knowledge possible. Please let us know if this article was helpful.
It didn't answer my question
This article was helpful
We’re glad we could help you today and appreciate your feedback. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information.
We're sorry this article didn't help you today. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic.
Last Updated: 02/12/2018