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The Comprehensive Error Rate Testing (CERT) Program
The CERT Program is a federally mandated, program integrity activity that was
established by the Centers for Medicare and Medicaid Services (CMS) to monitor
and improve the accuracy of Medicare payments to physicians and non-physician
practitioners.
Through the CERT Program, CMS calculates national, contractor specific,
contractor type, and provider type error rates. The CMS methodology includes
randomly selecting a sample of claims, requesting medical records from providers
who submitted the claims, reviewing the claims and medical records to see if the
claims complied with the Medicare coverage, coding, and billing rules, and
treating claims that are denied or down coded as errors and collecting
overpayment.
What is the Financial Impact to You?
Compliance with the CERT Program prevents unnecessary denials, overpayment
recoupment and appeals.
What You Need to Do
If you receive a CERT letter requesting medical records, you should:
- Respond Promptly.
Submit all of the documentation requested in the
letter and any additional documentation that you feel would support the
coverage and medical necessity of the services billed.
- Respond with Appropriate Documentation.
It is the responsibility of
the provider who billed for the service to submit all of the requested
documentation. This includes documentation residing with a third-party (e.g.
hospital, referring provider, lab).
- Attach the Bar Code Sheet.
Please attach the bar code sheet, provided
in the letter, in front of the medical records when sending the records to the
CERT Documentation Contractor. This bar code is used by CERT to log and track
the documentation that you submit.
- Customer Service.
A Customer Service line has been set up for
providers for general information and questions regarding the CERT Program.
The phone number is 1-301-957-2380.
- CERT Provider Address Website
. CERT has established a new website,
www.certprovider.org,
for providers to input contact information to enable CERT to request
information from the person in your facility responsible for medical records.
Please visit our CERT - Other Useful Web Sites Section for links to CERT information found on Government Health Care Sites such as CMS.
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