CERT Program Primary Objectives And Claims Status

CERT ProgramCERT Program supports CMS’s primary objectives of ensuring that Medicare contractors are paying claims appropriately, and providers are billing medically necessary services correctly. The error results help identify the areas of greatest vulnerability to the Medicare program, and will assist in directing educational activities to reduce the error rates. The errors are assessed to the Medicare Administrative Contractor (MAC) and the provider who billed the services. When an error is determined, the claim is adjusted by the MAC (e.g. CGS). Providers are notified of claims denied by CERT via their Remittance Advice (RA) or Electronic Remittance Advice (ERA). Provider can appeal any denial received as a result of a CERT review.

How to monitor the status of claims that were selected by CERT?

  • CGS has a CERT Claim Identifier Tool available to our providers to identify the outcomes of their claim’s CERT review. To use this Tool, you must have an established email and password. Once you have access to the tool, enter the Claim Identifier (CID) number assigned to the claim by CERT, and click ‘Submit’. You will see the CERT review date, the date of CERT’s letter(s) or phone call(s), if the claim was determined to be in error, and the CERT reviewer’s comments.

What if one of the claims receives an error?

  • CGS will adjust the claim, and either recoup money (overpayment) or pay additional money (underpayment).
  • Letters are sent from the CGS CERT Coordinator with details of your error. These letters are faxed to the fax number on file with the CERT office.
  • Sign up for myCGS where you can check on the status of any claim.
  • For Part A and home health and hospice providers, the adjusted claim can be identified in the Fiscal Intermediary Standard System (FISS) with a TOB ending in an “H” (e.g. 13H, 32H, 81H). Remarks indicating the reason for the CERT error will be entered on FISS Page 04.

Leave a Reply

Your email address will not be published.

Post Navigation