CERT Records Request Letters: Hints

CMS established the Comprehensive Error Rate Testing (CERT) program to measure the accuracy of Medicare payments. The accuracy of these payments is established through a review of selected claims submitted by health care providers and supporting documentation obtained from the corresponding medical records. Participation in the CERT review is not optional. It is imperative that you respond to requests for medical record documentation from the CERT contractor. No response equals no records, which in turn equals overpayments, and Palmetto GBA will request a refund from your practice. Although you have the same appeal rights with Palmetto GBA as in any other situation, this can be an unnecessary, time-consuming process.

To obtain the appropriate documentation for the CERT review, refer to both the bar coded sheet (which lists needed records) and the Medical Records/Documentation Pull List (which shows the specific codes and rendering provider's number).

If You Receive a CERT Records Request Letter

• You, as the billing provider, are responsible for taking the necessary steps to obtain records, even from third parties (e.g., hospitals, nursing homes, etc.)
• CERT will not pay for in-house or outsourced copying of any requested records. Please do not send them bills or invoices.
• The CERT record request letters do not specify the place of service. Only procedure codes, modifiers and diagnosis codes are listed. No narrative descriptions are given.
• Only the rendering/performing providers' Medicare Part B numbers will be shown. No actual names and designations are currently given.
• Be careful to obtain the correct records for the specific patient/date or dates of service/code(s) and provider. This is especially true if multiple providers from your practice performed services for the patient during the same time frames outlined in the letter. Pay particular attention to this if inpatient care was involved.
• The claim date and/or universe date are not the dates of service. They describe an "entry" date. It just represents the day when the processing of your submitted claim first began at Palmetto GBA. Please see service "from" and "to" dates for the actual date(s) of service.
• It is not a violation of HIPAA to send records for Medicare beneficiaries to the CERT Contractor. No signed release is needed*. Please notify your staff and medical records department of this.

* Exception: Psychotherapy where counseling session notes contain confidential exchanges between the therapist and patient. Psychiatric records, however, which are social, medical and administrative in nature, do not require special authorization (e.g., medication checks).

If you have questions concerning a request letter you have received, please contact the CERT Documentation Office at 888–779–7477.