Top Provider Questions – Comprehensive Error Rate Testing (CERT) Program
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- What are acceptable electronic signature notations?
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All patient medical record entries must be legible, complete, dated, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. Electronic signatures should contain date and timestamps and include printed statements (see below) followed by the practitioner's name and preferably a professional designation.
Examples of acceptable electronic signatures are, but not limited to:
- Chart 'Accepted By' with provider's name, designation
- 'Electronically signed by' with provider's name, designation
- 'Verified by' with provider's name, designation
- 'Reviewed by' with provider's name, designation
- 'Released by' with provider's name, designation
- 'Signed by' with provider's name, designation
- 'Signed before import by' with provider's name, designation
- 'Signed: John Smith, M.D.' with provider's name, designation
- 'This is an electronically verified report by John Smith, M.D.'
- 'Authenticated by John Smith, M.D.'
- 'Authorized by: John Smith, M.D.'
- 'Digital Signature: John Smith, M.D.'
- 'Confirmed by' with provider's name, designation
- 'Closed by' with provider's name, designation
- 'Finalized by' with provider's name, designation
- Digitalized signature: Handwritten and scanned into the computer. Be aware that electronic and digital signatures are not the same as 'auto-authentication' or 'auto-signature' systems, some of which do not mandate or permit the provider to review an entry before signing.
Indications that a document has been 'Signed but not read' are not acceptable
Reviewed 03/28/2024
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- What is CERT?
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The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) Program to measure improper payments in the Medicare Fee-for-Service (FFS) program. CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012.
Reviewed 03/28/2024
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- How does the CERT process work?
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- CERT selects a stratified random sample of claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs) during each reporting period.
- CERT requests supporting documentation from the provider or supplier who submitted the claim for payment.
- An independent medical review contractor reviews the documentation to determine if the claim was paid properly under Medicare coverage, coding and billing rules.
- If the documentation doesn't support that the criteria are met, or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment.
- CERT notifies the MAC who processed the claim if an improper payment is identified.
- The MAC adjusts the claim to recoup (for overpayments) or reimburse (for underpayments) the provider's payment.
- CMS calculates the annual Medicare FFS improper payment rate, which is published in the Health and Human Services (HHS) Agency Financial Report (AFR).
Refer to the CMS CERT webpage
for additional information about the CERT Program.Reviewed 03/28/2024
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- What information is sent to providers when a claim is selected by CERT?
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A letter is sent to the provider indicating that a claim has been selected for CERT review. The letter consists of several pages, including instructions for submitting your medical records, the timeframe by which the documentation must be received, and specific information to identify the claim that was selected. One page is a bar coded sheet that lists the specific documentation being requested for the claim and should be used as the fax cover sheet. The letter also contains the FAX number for which documentation should be sent to. Sample letters
can be accessed from the CERT C3HUB Provider website C3HUB (cms.gov).Reviewed 03/28/2024
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- Where does CERT send the request letters?
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Effective August 14, 2018, the CERT review contractor is sending initial Additional Documentation Requests (ADRs) to the address identified as the correspondence address in the PECOS data file.
Documentation Requests
- All FIRST ADR letters for CERT are sent to the address on file with PECOS for the provider/supplier that billed/submitted the claim.
- All SUBSEQUENT ADR letters can be sent to an alternate address. This can be provided to the CERT Customer Service Representative (CSR) by calling 888-779-7477.
The above processes are based on each individual CID; providers will need to contact the CERT office as mentioned above for each sampled claim.
See the Letters and Contact Information
on the C3HUB website.Chain Address Program
Providers who have at least ten (10) PTAN/OSCAR numbers who would like to elect a single point of contact (POC) can participate in the "chain address" program implemented by CERT. This program is as follows:- Call the CERT office (888-779-7477) or your local MAC CERT Coordinator (6153782.4591) with a list of PTAN/OSCAR numbers and the designated point of contact information.
- To assure you supply the information to CERT within the 45 days, CERT will email/call the point of contact with a list of outstanding CID numbers.
- NOTE: Due to the FIRST letter being sent to the provider address on file, these may be requests the point of contact has not yet received.
- When requested, the CERT CSR will forward a copy of the letters not yet received.
Group Calls
In order to reduce provider burden, when multiple calls are due to the same phone number, the CERT RC groups the calls so that a single contact can be made with the provider (providers) associated with that phone number to discuss all outstanding requests.IMPORTANT NOTE: This change is ONLY in regards to the CERT program.
Reviewed 03/28/2024
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- What should we do if our claim is selected for a CERT review?
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- Review the bar-coded sheet, included with the CERT letter, to determine what documentation is being requested
- Keep a copy of the CERT letter, including the bar-coded sheet, on file within your agency
- Gather all documentation requested in the letter, and any additional documentation that supports the coverage and medical necessity of all services billed for the dates of service indicated on the request
- Photocopy each record. Make sure all copies are complete, legible, and contain both sides of each page
- Place the bar-coded cover sheet in front of the documentation
- Send your documentation to the CERT Documentation Center. Acceptable submission methods are listed in the ADR letter and the Submit Records to CERT section of the C3HUB website.
Reviewed 03/28/2024
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- How long do we have to send in the requested documentation?
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Please see the initial and subsequent request schedules under Letters and Contact Information
on the C3HUB website.Reviewed 03/28/2024
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- What can we do to ensure our documentation is received timely?
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- Designate a CERT point of contact for your agency who will be responsible for receiving the request letters and/or telephone calls and for ensuring they are responded to timely
- Post a sample copy of the request letter where the mailed requests are likely to be received with instructions indicating to whom it should be routed
- Alert staff responsible for answering the telephone about the CERT process and give them instructions indicating to whom the call should be routed
- Make sure your main provider address and telephone number are correct as submitted on the provider enrollment form (CMS 855-A). If it is not correct, or if you have questions about submitting a corrected form, contact the CGS Provider Contact Center.
- For questions or comments related to the Request for Medical Records, you may call the CERT Customer Service Representative at 888.779.7477.
Reviewed 03/28/2024
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- Do we need the beneficiary's authorization to release the information to the CERT contractor?
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No, Medicare beneficiaries have already given authorization to release medical information in order to process claims. It is not a HIPAA violation to submit documentation to the CERT contractor.
Reviewed 03/28/2024
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- Do we need to obtain all the documentation/information from our associated providers?
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Yes, it is the responsibility of the billing provider to respond to the request for medical records related to the care you provided. This includes all medical records that reside with a third party (e.g. clinics, labs, hospitals, physicians).
Reviewed 03/28/2024
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- Who are the errors assessed to?
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The errors are assessed to the Medicare Administrative Contractor (MAC) and the provider who billed the services. When an error is determined, the claim is adjusted by the MAC (e.g. CGS). Providers are notified of claims denied by CERT via their Remittance Advice (RA) or Electronic Remittance Advice (ERA). Provider can appeal any denial received as a result of a CERT review.
Reviewed 03/28/2024
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- What outcomes are expected from the program?
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The CERT Program supports CMS's primary objectives of ensuring that Medicare contractors are paying claims appropriately, and providers are billing medically necessary services correctly. The error results help identify the areas of greatest vulnerability to the Medicare program and will assist in directing educational activities to reduce the error rates.
Reviewed 03/28/2024
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- What if we have additional documentation that we did not originally send with the request?
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You may send additional documentation to the CERT Documentation Center (CDC) at any time, even if it is after the requested time frame. Be sure to include a copy of the bar-coded cover sheet to identify the claim identification (CID) number associated with your documentation.
Reviewed 03/28/2024
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- Why would the CERT contractor consider my claim an error?
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The CERT Assignment of Error Categories
document on the CMS website explains when a claim is placed in one of the five major error categories. Tips on how to avoid these errors are listed below.- No Documentation
- Submit supporting documentation for the service(s) billed within the timeframe indicated on the request. See Avoid CERT No Documentation Errors for additional information.
- Insufficient Documentation
- Review the barcoded cover sheet for a list of documents typically needed to support Medicare payment. The provider that billed the claim is responsible for maintaining and submitting all documentation necessary to support the services billed. In some cases, you may need to obtain records from a different provider (e.g., referring/ordering provider or rendering provider/facility) and/or for dates prior to and/or after the billed date of service.
- Medical Necessity
- Ensure the documentation you submit clearly illustrates compliance with all applicable Medicare statutes and regulations, billing instructions, National Coverage Determination (NCDs), Local Coverage Determinations (LCDs), and provisions in the CMS Internet-Only Manuals (IOMs).
- Incorrect Coding
- Ensure the documentation you submit supports the codes reported on the claim (e.g., procedure and diagnosis codes correspond with AMA/ADA/NUBC coding guidelines; HIPPS codes correspond with patient assessments; patient discharge status codes correspond with the patient's location/care received after discharge/transfer).
- Other
- Ensure the documentation you submit, including a signature, is legible. If necessary, include a signature log or attestation.
Reviewed 03/28/2024 - No Documentation
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- What happens if one of our claims receives an error?
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- CGS will adjust the claim, and either recoup money (overpayment) or pay additional money (underpayment).
- Letters are sent from the CGS CERT Coordinator with details of your error. These letters are faxed to the fax number on file with the CERT office.
- Sign up for myCGS where you can check on the status of any claim.
- For Part A, Home Health and hospice providers, the adjusted claim can be identified in the Fiscal Intermediary Standard System (FISS) with a TOB ending in an "H" (e.g. 13H, 32H, 81H). Remarks indicating the reason for the CERT error will be entered on FISS Page 04.
Reviewed 03/28/2024
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- What is a CERT additional documentation request?
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While conducting medical review of the documentation received, the medical review specialist may identify the need for additional information. A new additional documentation request (Tech Stop) will be issued to obtain the specific item of missing documentation. The response time for this second request is shorter. The CERT Review Contractor follow this schedule:
Subsequent Request Schedule- Day 1: Send letter 1
- Day 1: Telephone contact to follow-up on request and/or offer assistance.
- Day 10: Send letter 2
- Day 10: Telephone contact to follow-up on request and/or offer assistance.
- Day 16: Claim back in review process
Reviewed 03/28/2024
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- Where can I get more information about the CERT program?
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The following list provides additional resources regarding the CERT Program.
Reviewed 03/28/2024
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- Can a CERT error result in a Unified Program Integrity Contractor (UPIC) referral?
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It is important to note that the improper payment rate is not a "fraud rate," but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.
Reviewed 03/28/2024
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- What causes a CERT error?
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CERT errors are typically NOT because the services were NOT necessary. Rather, CERT errors usually indicate a failure to submit documentation, or a lack of documentation to support the medical necessity of the services provided. It is important that you respond to any CERT request timely, as no response, or submitting insufficient documentation, will result in a CERT denial and recoupment of Medicare payments.
Reviewed 03/28/2024
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- How do I avoid SNF Certification errors?
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The initial certification is due at the time of admission, or as soon thereafter that is reasonable.
- The first recertification MUST be made no later than the 14th day of inpatient extended care services
- Subsequent recertifications are required at intervals NOT to exceed 30 days
Delayed certifications/recertifications are allowed for an isolated oversight or lapse. A delayed cert/recert MUST include an explanation of the delay along with any other information the SNF considers relevant to explain the delay
References:
- CMS Internet Only Manual (IOM) 100-08 Medicare Program Integrity Manual, Chapter 6, sec 6.3
- CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 8, sec 40
Reviewed 03/28/2024
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- What are the requirements for IRF claims?
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For Inpatient Rehabilitation Facility (IRF) services to be covered under the Medicare IRF benefit, submitted documentation must sufficiently demonstrate that a beneficiary's admission to an IRF was reasonable and necessary, according to Medicare guidelines.
The Medicare IRF benefit provides intensive rehabilitation therapy in a resource intensive inpatient hospital environment, including Inpatient Rehabilitation Hospitals and Inpatient Rehabilitation Units. The IRF benefit is for a beneficiary who, due to the complexity of their nursing, medical management, and rehabilitation needs, requires AND can reasonably be expected to benefit from a inpatient stay and an interdisciplinary team approach to rehabilitation care. Please review the guidance provided in the CMS MLN Educational Tool: Medicare Provider Compliance Tips
.Reviewed 03/28/2024
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- Where can I find help with Two Midnight requirements?
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Refer to the following resources.
- SSA 1862(a)(1) (A)
- 42 CFR 424.11(General procedures)
- Medicare Program Integrity Manual, Pub. 100-08, Ch. 6 §6.5.2, A. (Determining Medical Necessity and Appropriateness of Admission)
- CMS Acute Inpatient PPS, Details for title: CMS-1599-F and other associated rules and notices Web page.
Reviewed 03/28/2024 - SSA 1862(a)(1) (A)
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- I am getting errors for incorrect Discharge Status and don't understand why.
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Patient discharge status codes identify where a patient is at the conclusion of a health care facility encounter or at the end of a billing cycle. It is important to select the correct patient discharge status code because it may affect your payment. For guidance on determining the correct patient discharge status code to use when completing your claim, please refer to the Patient Discharge Status Codes Matter
article.Reviewed 03/28/2024
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Updated: 11.21.2025
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