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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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09/30/2011 - Updated 10.12.16

The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests

What is the Comprehensive Error Rate Testing (CERT) Program?

The CERT Program is a federally mandated program set in place to monitor and improve accuracy of Medicare payments. This program created a way for the Centers for Medicare & Medicaid Services (CMS) to look at the Paid Claim Error Rate and provider compliance for CGS.

Who administers the CERT Program?

On August 16th, 2016, CMS awarded the CERT Review Contractor work to AdvanceMed, an NCI company. This new contract eliminates the current CERT Documentation Contractor as of October 13th, 2016.

The CERT Review Contractor (CRC) will now request/review the submitted records and notifies the Medicare Administrative Contractor (MAC) of the claim review decision
The CERT Contractors: ◦Randomly select claims processed by a Medicare contractor for CERT medical review
- Perform the medical review of the claims selected
- Determine accuracy of claim payment
- Determine recoupment of monies, if necessary
- Calculate the paid claim error rate
- Report this information to CMS

What is a paid claims error rate?

The paid claims error rate is the percentage of total dollars that Medicare contractor erroneously paid or denied for claims and is a good indicator of how claim errors impact the Medicare trust fund. This rate is based on dollars processed after the MAC has made its payment decision on the claim and includes paid and denied claims.

How will CMS use this information?

CMS uses the CERT contractor's findings to determine underlying reasons for errors in claim payments or denials, and to implement appropriate provider corrective actions aimed toward improvements in the accuracy of claim submissions and systems of claims processing.

What is included in a CERT request?

The CERT request is mailed in a dark tan envelope and includes the following:

'Immediate Response Required' printed in red on the envelope, 'Medicare Response Required' printed in black on the envelope
Information about the CERT process
List of information to submit
Where to mail or fax the documentation
Time frame for responding
Contact name and number to contact CERT with questions or comments
Claim information
Bar-coded page
CERT claim ID number (CID)
Health Insurance Portability and Accountability Act (HIPAA) compliance

Note: HIPAA does not preclude providers from sending requested medical records or documentation to a Medicare contractor. Medicare beneficiaries, upon enrollment in the program, are informed of Medicare's use of their personal health information to carry out health care operations.

The list of items requested in the CERT letter is not all-inclusive. Providers should send all information necessary to support coverage and medical necessity of the services billed.

How does compliance with the CERT Program benefit the provider?

Ensures the appropriate reimbursement of the provider's claims
Prevents unnecessary denials and the need to request an appeal/redetermination
Reflects a positive impression of a provider industry by having a low error rate
May prevent additional medical review of the provider and their industry
Helps support the solvency of the Medicare program

What should the provider do when a request for records is received from the CERT contractor?

Be alert to these requests from the CERT contractor
Educate agency staff who receive the mail, on how to identify CERT letters and where to forward the request within the agency
Refer to the list of items included in the CERT letter when responding

Note: This list is not all-inclusive. Send all documentation to support services and/or items billed.

Place the bar-coded cover sheet in front of the documentation when submitting records to the CERT contractor
Separate each response and paper clip or rubber band the ORIGINAL bar-coded sheet to each individual set of records
Remember to update the provider contact information with the CERT contractor so you may be contacted, if necessary
If responding to multiple requests on the same beneficiary for various dates of service, respond to each request separately
Return the ORIGINAL bar-coded sheet – please do not send a photocopy
Respond to the CERT request within 75 days
The CERT contractor prefers that the information be faxed to their office. Instructions on how to do this are included in the multi-page letter.

Note: If records are faxed to the CERT contractor, the CERT contractor will send a fax confirmation of receipt of records to the provider. The confirmation letter will include the CID number only for identification purposes. If a confirmation letter is not received, the provider may call the CERT contractor to verify the receipt of records.

If the provider chooses to mail the CERT response, it is recommended that the CERT response be mailed by return receipt mail
Request and include needed documentation from third parties if applicable
Fax or mail the requested information to the number or address listed in the CERT contractor letter

Note: It is the provider's responsibility to make requested medical records available to the CERT contractor even if they reside with a third party.

How can the provider change their medical review correspondence address on file with the CERT contractor?

The provider mailing address and phone number on file with the CERT contractor may be viewed at CERT Provider website (https://c3hub.certrc.cms.gov/) for accuracy. This website is considered a public site and users may download a form to submit changes to their contact information through e-mail or providers may update the mailing address and phone number by contacting the CERT contractors' customer service call centers at (888) 779-7477

What should providers avoid when responding to CERT requests?

Delaying their response to the request
Stapling the original bar-coded sheet to the records
Submitting a photocopy of the bar-coded sheet
Punching holes in the records as this may obscure valuable information

What information should be submitted by the provider in response to the CERT contractor request for records?

Checklists for all provider benefit types were created by the Medical Review department at CGS. To view these checklists, select the PDF documents below. Refer to the CERT checklist depending on the type of claim. These checklists are helpful tools and are not all-inclusive. Please submit all documentation to support the medical necessity of the services under review.

What happens if the provider does not respond to the CERT contractor request for records?

Providers have 75 days to respond with the requested information, even if the records reside with a third party. Non-submission of documentation or incomplete documentation will result in a reduction or denial of payment. Providers with documentation that has been logged with the CERT contractor will not receive continued follow up calls and letters unless requested documentation is missing.

What is the outcome of CERT review?

The CERT contractor notifies CGS of their determination only when there has been a change in the original claim decision.

CGS will adjust the claim
For a Part A claim, the adjusted claim can be identified by an XXH type of bill on the remittance advice. The 'H' represents a CMS denial decision.
CERT denials will appear on the provider's remittance advice when the CERT contractor denies some or all of the claims or lines reviewed
CGS will send an educational CERT Teaching and Instruction for Providers (TIP) Letter to explain the reason the claim was adjusted

Note: TIP letters are for educational purposes only and are not denial notifications for appeals/redeterminations.

Appeals/redeterminations of denials made by the CERT contractor should be submitted to CGS following the normal appeal/redetermination process

Do I have appeal/redetermination rights if my claim(s) is/are denied by the CERT contractor?

When the provider has claims denied by the CERT contractor, a request for an appeal/redetermination may be submitted to CGS following the normal appeal/redetermination process. The time limit for filing a request for a redetermination is 120 days from the date of the remittance advice for all lines of business.

Additional Questions

Additional information about the CERT program is accessible from the following website:

CMS website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html

The CERT Contractor call center operates between the hours of 8 a.m. to 6 p.m. ET, and their phone number is 443.663.2699 (or) toll-free (888) 779-7477.