CERT Contractor EDI Claims Checking

CERT Contractor EDI Claims Error Checking

CERT Contractor may consider claims sent by providers and Medicare partners having errors. Errors may result for the following reasons:

• • No Documentation Received
    • This results when the provider fails to respond to the request for medical records, or responds to the request untimely. In order to avoid these types of errors, be sure to respond within the timeframe indicated on the request.
  • Insufficient Documentation
    • The majority of errors are due to insufficient documentation. In order to avoid these types of errors, be sure to submit all applicable information to support the services billed on the claim, and listed on the documentation checklist included in the CERT request. Remember, it is your responsibility to gather any supporting documentation from third parties such as hospitals, labs, skilled nursing facilities, or ordering physicians, etc.
  • Medically Unnecessary Services or Treatment
    • All services provided to Medicare beneficiaries MUST be medically necessary. Documentation to support that medical necessity must be submitted for review. Submit all applicable information that supports the medical necessity such as physician’s orders, assessments, plans of care, etc.
  • Incorrect Coding
    • These errors result when the documentation submitted supports either a different code, or a different number of services. In addition, the documentation must accurately support the number of service units billed.
      • For home health providers, the documentation must support the answers completed on the OASIS, as well as the HIPPS code submitted on the claim.
      • For Part A and Part B providers, the documentation must support the CPT code as outlined in the AMA CPT book that covers the year in which your service was performed.
  • Improper Documentation
    • This error results when the documentation submitted is for the correct beneficiary and dates of service on the request. To avoid this, be sure to check the request against the records being sent.