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CERT - Comprehensive Error Rate Testing Program What is CERT? In an effort to determine the rate of Medicare claims that are paid in error, CMS has developed the Comprehensive Error Rate Testing (CERT) program. This program will determine the paid claim error rates for individual Medicare contractors, specific benefit categories, and the overall national error rate. This is accomplished by sampling random claims on a nationwide basis, while insuring that enough claims are sampled to evaluate the performance of each Medicare contractor. The CERT program is administered by two contractors: CERT DOCUMENTATION CONTRACTOR (CDC) - The CDC requests and receives medical records from providers. CERT REVIEW CONTRACTOR (CRC) The CRC’s medical review staff reviews claims that are paid and validate the original payment decision to ensure that the decision was appropriate. The sampled claim data and decisions of the independent medical reviewers will be entered into a tracking and reporting database. The outcomes from this project are a national paid claims error rate, a claim processing error rate, and a provider compliance rate. The tracking database allows us to quickly identify emerging trends. 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 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:
05/01/2008 |
