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The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to produce a national error rate. Error rates are determined based on review of medical records from regularly sampled claims submitted to Medicare for payment. Records are reviewed to ensure that claims were paid or denied correctly.
When submitting records for review:
Make sure all submitted documentation is legible
Submit records for all dates of service on the claim
Ensure that the medical records submitted provide proof that the service(s) was ordered by the MD and rendered. Also provide justification to support the medical necessity.
Requests for Medical Records
The CERT Documentation Contractor (CDC) may request copies of your medical records.
Letters requesting medical records for services performed within
the past year are sent to Medicare providers each month.
These letters include requests for documentation of lab tests (e.g.
urinalysis), surgical procedures (e.g. cataract extractions or office
procedures), or other services (e.g. chemotherapy infusions). Evaluation
and Management (E&M) services represent the largest number of records requested.
Comprehensive Error Rate Testing (CERT) Request
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HIPAA
regulation and state law support sending the requested medical records to the CDC.
Providers who receive requests for medical records from CDC should send
documentation directly to the CDC at the address listed on
the request. If you submit records to the
CDC with the wrong date of service, or delay your response beyond the allowed submission time,
CERT will presume the service was never done and a refund of payment will be collected. If
providers prefer to submit the medical records to NHIC, Corp., please call the AC Point of
Contact first for assistance.
NOTE: Late documentation will be reviewed by the CRC. If the review result is favorable, the original CERT decision will be reversed.
NHIC wants to pay claims correctly the first time and needs your active
participation to lower the payment error rate. A favorable payment error rate
reflects well on the entire Medicare program.
For additional information:
- Refer to the Frequently Asked Questions.
- View CERT Newsletters- The purpose of the CERT Newsletter is to provide an exchange of information among CMS, the CERT Review Contractor (CRC), the CERT Documentation Contractor (CDC), and Affiliated Contractors (ACs), and Providers.
- CERT Monthly News Articles
- CERT Education–
- NHIC Medicare Education and Outreach has long provided our customers the opportunity to learn about the Medicare program and changes that affect everyone through various educational programs. Please find below the presentations that have been provided by Provider Outreach and Education on the overview of the CERT program, most current issues found as result of CERT audits and tips on how to appeal denied claims and prevent future errors.
- For more information regarding the CERT process you may contact NHIC (AC Point of
Contact):
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07/01/2010
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