The Importance of Complying with Requests for Claim Documentation
The 2004 national gross paid claims error rate was 10.1 percent. A portion of this error rate was due to providers not sending requested supporting documentation to the designated CERT contractor. Medicare FFS physicians, providers and suppliers must provide documentation and medical records that support their claims for covered Medicare services to the designated CERT contractor upon request. If you fail to submit documentation, the claim will be considered an error and you will receive a demand letter requesting refund of payment received for the "erroneous" claim.
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 (CRC) 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.
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.
In an effort to assist Medicare physicians, providers and suppliers with CERT compliance, there are several resources available to explain the CERT process and how your responsiveness is in everyone's best interest.
- CERT Web Page

- CERT Newsletters

- A designated telephone number for Medicare physicians, providers and suppliers for general information and questions regarding the CERT initiative – 804.864.9940.
REMEMBER:
- A review can result in identification of overpayments as well as underpayments
- If CERT changes the payment decision on you claim by denying or reducing payment, you can still file an appeal with your Medicare contractor.
- It is in everyone's interest to code and pay claims correctly. Your support of this process helps protect the solvency of the Medicare Program.

