CERT Program Processing
CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period. The sample of Medicare FFS claims is reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding and billing rules. If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments). The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the Health and Human Services (HHS) Agency Financial Report (AFR).
A letter is sent to the provider indicating that a claim has been selected for CERT review. The letter consists of several pages, including instructions for submitting your medical records, the timeframe by which the documentation must be received, and specific information to identify the claim that was selected. One page is a bar coded sheet that lists the specific documentation being requested for the claim. The letter also contains the FAX number for which documentation should be sent to.
Effective August 14, 2018, the CERT review contractor is sending initial Additional Documentation Requests (ADRs) to the address identified as the correspondence address in the PECOS data file.
Documentation Requests
- All FIRST ADR letters for CERT are sent to the address on file with PECOS for the provider/supplier that billed/submitted the claim.
- All SUBSEQUENT ADR letters can be sent to an alternate address. This can be provided to the CERT Customer Service Representative (CSR) by calling 888-779-7477.
The above processes are based on each individual CID; providers will need to contact the CERT office as mentioned above for each sampled claim.
Chain Address Program
Providers who have at least ten (10) PTAN/OSCAR numbers who would like to elect a single point of contact (POC) can participate in the “chain address” program implemented by CERT.