CERT Fact Sheet
Currently, CMS (Centers for Medicare & Medicaid Services) calculates a national paid claims error rate, a contractor specific error rate, and a provider compliance error rate (which measures how well providers prepared claims for submission).
The CMS methodology includes:
- Randomly selecting a sample of claims submitted in a specific calendar year;
- Requesting medical records from providers who submitted the claims;
- Reviewing the claims and medical records to see if the claims complied with the Medicare coverage, coding, and billing rules; and
- Treating the claims as errors and sending the providers overpayment
letters when:
- Providers fail to submit the requested documentation
- Providers submit insufficient documentation, or
- The submitted medical record indicates that the service was not medically necessary, incorrectly coded, or was not in compliance with some other Medicare coverage or billing rule.
What You Need to Do
Provide requested information
During a CERT review, you may be asked to provide more information related to a claim you submitted, such as medical records or certificates of medical necessity, so that the CERT review contractor can verify that billing was proper. Be assured that forwarding specifically requested records to the designated CERT contractor does not violate privacy provisions under the Health Insurance Portability and Accountability (HIPAA) law. Make sure your office staff is aware that this request for additional documentation must be answered.
Respond Promptly
If you receive a letter from CMS regarding a CERT request for medical documentation, you should respond promptly by submitting the requested supporting documentation within the time frame outlined in the request. Physicians, providers and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor.
Keep your enrollment information current.
It is vitally important for providers to keep enrollment information current. When providers change mailing address, phone numbers, practice location, etc., it is important to keep your Medicare contractor informed within 90 days of the change. Correct address information will help ensure that CERT documentation requests are received and will allow time for your response.
These changes must be done by completing the _CMS 855I application (Individual)
or CMS 855B application (Group or Organization) application to change your
information. These forms and instructions can be found on our website at http://www.cgsmedicare.com under
Provider Enrollment or on the CMS website at www.cms.hhs.gov
.
If you have additional questions after reviewing these resources, please call
our Provider Enrollment Department at 866.520.4007 hours 9:00 am- 3:00 pm (CST).
Important Information
If you fail to submit the requested information in a timely fashion, an "error" is registered against both the Medicare contractor and you as the Medicare provider. (At this point, the CERT review contractor has no choice but to register the claim submission as "erroneous" because there is insufficient supporting documentation to determine otherwise.) Treating these claims as errors will prompt the CERT reviewer to instruct CGS to send the providers overpayment letters. Also, these errors have a corresponding negative impact on the other error rates that are calculated under the CERT program.
More information can be found on the CGS website.
If you have questions or need assistance you can reach your CERT Coordinator, Julene Lienard, at 615.734.4191 or julene.lienard@cgsadmin.com
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