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.
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.
Examples of requests based on common denials:
- Inpatient hospital entire record
- Documentation to support medical necessity of inpatient hospital admissions vs. outpatient care setting - especially for short stays
- Records of prior diagnostics and treatments - prior to inpatient hospital surgery
- Documentation of coverage indications for pacemakers
- Documentation to support DRG coding
- Order for admission of hospital and SNF and MD certification of SNF care
- Hospital discharge summary - signed by physician to support subsequent SNF stay
- MD orders for diagnostics - including MD signature and verification of illegible signature
- MD certification of therapy treatment plans
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.
Please send the information to the CDC as requested. When records are
not received, the CERT Review Contractor (CRC) must assume that the services were not
provided and NHIC must request a refund of the payment.
The CERT Documentation Contractor Needs Help Obtaining Provider Phone Numbers
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Missing or illegible signatures are increasing the CERT error rates for NHIC, Corp. region. The signature requirements are indicated in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-08, Chapter 3, Subsection 220.127.116.11 which notes Medicare contractors require a legible identifier for services provided/ordered. Please visit this section of the IOM on the CMS website for signature requirements information.
For CMS guidance regarding signature requirements, reference MLN Matters Article: Signature Requirements MM6698
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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 (fax preferred or if record too large for fax -CD preferred) at the fax number or 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. Appeal is best course of action for denied claims but if late documentation submitted, it 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.
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