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 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

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.

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.
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 website.
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.
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.
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.

Print | Bookmark | Font Size: + | –

October 3, 2011

Part A Comprehensive Error Rate Testing (CERT) Fact Sheet

What is the CERT process?: The CERT process created a way for the Centers for Medicare and Medicaid Services (CMS) to look at the Medicare accuracy of claims processed by all Medicare Administrative Contractor (MAC). The CERT contractor reviews a random sample of processed claims.

What is the CERT contractor?: The CERT Review Contractor (CRC) is an independent company that determines the paid claims error rates. The CERT Documentation Contractor (CDC) obtains medical records for claims selected as part of the CERT review process. The CERT contractors are not part of CGS.

What is a "paid claim error" rate?: This rate is based on dollars processed after the MAC made its payment decision on the claim. These rates include paid and denied claims. The paid claims error rate is the percentage of total dollars the FI erroneously paid or denied. This is a good indicator of how claims errors impact the Medicare trust fund.

How does the CERT process work?: The CDC randomly selects processed claims, then requests and receives medical records. The CRC reviews the submitted records and makes a determination as to whether the claim processed and paid correctly.

Are healthcare providers required to comply with the CERT contractor's request for medical records?: Yes. The CERT process is a federally mandated program. Non-submission of medical records may result in a denial or reduction in payment for the provider.

How is compliance with the CERT contractor's request for medical records beneficial to providers?: Compliance with the CERT process benefits the provider by ensuring the appropriate reimbursement of the provider's claims, preventing unnecessary denials and appeals, may prevent additional medical review of providers and/or provider industry, and reflects a positive impression of the provider industry by having a low error rate.

How does the CERT contractor's request for medical records impact HIPAA compliance issues?: Providing medical records of Medicare patients to the CERT contractor is within the scope of compliance with HIPAA.

How will providers recognize a CERT contractor request for medical records?: CERT requests will either be mailed or faxed. If mailed, the request will arrive in a tan envelope printed with the words Immediate Response Required. The letter contains specific information on the CERT process, HIPAA compliance, documentation to submit, where and how to submit the documentation, timeframe for responding to the request, claim information and an ORIGINAL bar coded sheet to include with your response. Please note that the list of documentation to submit in response to the CERT contractor's request is not all-inclusive. The provider should respond with all documentation necessary to support the medical necessity of the services provided.

What should the provider do if multiple requests for medical records are received from the CERT contractor?: Respond to each request separately. The provider may receive multiple requests on the same beneficiary for the same or different dates of service. Attach the ORIGINAL bar coded sheet to each individual set of records. When submitting the medical records, follow the instructions in the letter for submission of medical records. Each request has a CERT claim identification number or CID. The CDC prefers to receive records via fax (240) 568-6222.

What should a provider do if they have a question about the CERT contractor's request?: The CERT letter contains instructions on how to contact the CERT contractor. CGS has established a voice mail phone line for CERT questions: (803) 763-7491. If you contact the CERT contractor or CGS with questions, please have the CID number available. You must use the CID number to obtain specific information regarding CERT requests for medical records.

What is the time frame for responding to the CERT contractor's request for medical records?: The provider has 75 days to respond to a request. During this time, if the provider has not responded, they may receive a second and third request or an Office of Inspector General (OIG) request for the medical records. Subsequent requests for the same medical records have shorter response time frames. The provider may also receive telephone calls from the CERT contractor and/or CGS.

How long does the CERT contractor have to review the medical records?: There is no set time frame for the medical review by the CERT contractor.

How will the provider be notified of the review decision?: The provider is not notified if the CRC agrees with the original determination. If the CRC disagrees with the determination, the MAC is notified of the CRC's decision and the MAC will adjust the claim. Adjustments can be identified on the provider's remittance advice by an H on the end of the type of bill.

May the provider appeal the CERT contractor's decision?: Yes. Follow the normal redetermination process to appeal all CERT denials. Refer to the CGS Medicare Part A Request for Redetermination Form.

Is your address current?

The CERT contractor uses the mailing address on file with the MAC. Ensure that your address is correct with CGS.

Visit the CMS website (784 KB) to obtain a CMS 855A form to update provider enrollment information at CGS. The 855A application cannot be sent electronically. An original signature is required, so the form must be printed, signed and mailed.
To contact the Provider Contact Center and providers call (866) 830-3455.
Visit www.certprovider.org to view the provider mailing address and phone number the CERT contractor has on file. Contact information may be updated by calling the CERT customer service call center at CDC (888) 779-7477 or CRC (804) 864-9940.

Visit the following websites

Go to the CGS Part A website and select General Information
Look for the article The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT requests. Checklists are attached for use in responding to CERT requests.
CERT Documentation Contractor website
CMS CERT Web page

Latest News!

Information is the key to reducing CERT errors!
The #1 reason for CERT problems is inaccurate billing. Ensure the accuracy of your billing to avoid CERT denials.