Corporate

Comprehensive Error Rate Testing (CERT) Program

Program Overview

The Comprehensive Error Rate Testing (CERT) program was established by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claim payment in the Medicare Fee-For-Service (FFS) Program.

The intent of the CERT program is to protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels. Findings from the CERT program are used to identify trends that are driving the errors, such as errors by a specific provider type or service, and assist with allocation of future program integrity resources. The CERT error rate is also used by CMS to evaluate the performance of Medicare contractors, like CGS.

Claim Selection and Requests

Claims are randomly selected for CERT review. When a claim is selected for review, the CERT review contractor will send a letter to the provider requesting medical documentation be submitted for CERT review. To ensure your letter is a valid CERT request, the first page contains the CMS logo and a barcode. Be assured that forwarding specifically requested records to the CERT review contractor does NOT violate privacy provisions under the HIPAA law.

The letter from the CERT program will identify the individual claim selected and different methods for submitting the documentation. A sample CERT letter can be found on the CERT Provider websiteExternal Website by clicking on 'Sample LettersExternal Website'. Select the English or Spanish version of the 'Part A Initial Letter' to view letters applicable to home health and hospice providers.

Responding to CERT Requests

The CERT request letterExternal Website (Additional Documentation Request (ADR)) identifies the claim selected, the documentation being requested, and also includes instructions to place the bar-coded coversheet as the only coversheet to the top of your documentation. It also provides the different methods that may be used to submit the documentation. All documentation related to the services provided must be sent to the CERT Documentation Center within 45 days of the request. However, sending your documentation sooner is strongly recommended.  Refer to the CERT Letter and Contact Schedules Web pageExternal Website for details.

Note for Home Health Providers: For home health recertifications and subsequent episodes that are selected as part of the CERT program's audit, the original face-to-face (FTF) encounter documentation and original certification should be submitted, in addition to any documentation that supports the recertification/subsequent episodes.

Status of CERT Claims

The CERT Claim Identifier Tool is available for CGS providers to determine the outcome of a CERT reviewed claim, and the reviewer's comments for a claim denied by CERT. Enter the Claim Identifier (CID) number assigned to the claim by CERT, and the results of the CERT review will appear. You can also select the National Provider Identifier (NPI) Number button, and enter your NPI number to view the results of all CERT claims for your agency.

Providers with questions specific to a claim reviewed by CERT can contact the CGS CERT Coordinator at 615-782-4591.

Point of Contact

All FIRST Additional Documentation Request (ADR) letters for CERT are sent to the address on file with the National Supplier Clearinghouse (NSC) for Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) suppliers, or the Medicare Administrative Contractor (MAC) for the provider/supplier that billed/submitted the claim.  All SUBSEQUENT ADR letters can be sent to a specific correspondence address. This can be provided to the CERT Customer Service Representative (CSR) by calling 888.779.7477.  Refer to the Comprehensive Error Rate Testing (CERT) Program New Processes article for additional information.

Why Be Concerned?

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 home health or hospice 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.

CERT Errors and Education

To help reduce the CERT Error Rate, CGS believes provider education on the CERT errors allows home health and hospice agencies to determine the types of errors identified by CERT, and empowers providers to review their internal processes to eliminate similar errors. To review the most recent CERT errors among CGS providers, and educational resources to avoid those errors, review the Summary of CERT Errors Web page.

To learn more about the CERT Program, review the links below.

Updated: 07.20.18

Was this page helpful? YES NO


Two Vantage Way, Nashville, TN 37228 © CGS Administrators, LLC. All Rights Reserved