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Documentation Requirements 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. 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:
10/22/2008 |
