LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

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

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Corporate

Print | Bookmark | Email | Font Size: + |

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://www.certprovider.comExternal Website) 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:

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.

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved