Guide to CERT Request Letters
CERT Response Time
Providers are required to supply medical records to the CERT Contractor within 45 days. Providers may receive up to four initial request letters as well as several phone calls. If the medical records are not received by the 76th day of the initial request, the review will be counted as a non-response error. At this point, CERT will request that Palmetto GBA recoup the entire payment for the claim in question.
Once a provider submits their medical records in response to the initial request, the claim is reviewed by CERT. If documentation is missing that would affect payment of the claim, a subsequent or follow-up additional documentation request letter will be sent to the provider. Up to two letters as well as phone calls may be completed. However, the time frame is shortened to 15 days for a response. On the 16th day, the record is returned to the CERT reviewer to finalize their review. Denial or recoding of services will likely result if a provider fails to respond to the request for the missing documentation.
Key Points
- Palmetto GBA may have processed your Part B claim, but two other contractors handle functions associated with the actual claims sampling and review. They are known as the CERT Review Contractor (CERT RC) and the CERT Statistical Contractor (CERT SC).
- These are post pay audits of Medicare Part B claims and records. This means that because your services were submitted to Medicare for payment consideration, the Centers for Medicare & Medicaid Services (CMS), by law, has the authority to examine your records for the presence of valid and corroborating documentation.
The links below contain CERT letter examples from the C3HUB. These examples include explanations and page-by-page references for CERT sample letters. Refer to the C3HUB tab ‘Sample Request Letters’.
