About CERT/HIPAA

CERT Process Overview

The CERT contractor randomly requests and audits approximately 4,000 claims per year from Jurisdiction B. At that time they also receive the provider address listed in the system so that they can request the record for review. CERT will send up to four letters to the provider requesting the records, one every 20 days or so. Providers have 90 days before the claim is counted toward the Provider Compliance Error Rate.

The medical review specialists employed by the CERT contractor review each claim and determine the following:

• Does the item/equipment fit a Medicare benefit category?
• Is the item/equipment statutorily excluded?
• Is the item/equipment medically reasonable and necessary?
• Is there documentation to support that the item/equipment was provided?
• Was the item/equipment coded and billed correctly?

Twice a month the CERT contractor sends a file to CGS that includes all the claims found to be in error. CGS adjusts the claims based on whether the error resulted in an overpayment or underpayment. The provider will receive a Remittance Notice for each adjustment, whether it is correcting an overpayment or underpayment. CGS also requests refunds on errors that resulted in overpayments.

If an error is not found after the claim is reviewed by the CERT contractor, no response will be sent to the provider.

Appeals for CERT Errors

A redetermination (1 st level appeal) may be requested if you feel a CERT error was called incorrectly. Suppliers have the same appeal rights for CERT initiated denials as they do for denials initiated through CGS. For more information about the appeals process and a request form, refer to the Appeals section of our website.

When requesting a redetermination, be specific about why you feel the denial was incorrect. Send additional documentation and medical records that may be available to support the medical need for the item(s) denied. To find out more about what documentation may have been missing or why the error was called, contact our CERT Coordinator, Brenda Normandia, at 615-782-4485.

HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that allows people to immediately qualify for comparable health insurance coverage when they change their employment relationships. Along with the standardization of the exchange of electronic data and the requirement for the use of national identification systems, HIPAA has also specified the types of measures required to protect the security and privacy of personally identifiable health care information.