CERT

Published 06/16/2022

The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. The objective of the CERT program is to estimate the accuracy of the Medicare FFS program. It assesses the success of our work as a Medicare contractor to reimburse providers correctly while protecting the Medicare Trust Fund and is intended to improve the processing and medical decision making involved with the payment of Medicare claims. The CERT program produces national and contractor specific error rates that are posted on the CMS website.

References

Last Reviewed: 6/16/2022

The CERT Review Contractor (CRC) selects a stratified random sample of Medicare FFS claims for review based on claim type. The CRC then requests documentation to support that service from the provider or supplier who submitted each of the claims in the sample. Once the documentation is received it is reviewed by independent medical reviewers to determine if the claim was paid properly by the MAC under Medicare coverage, coding, and billing guidelines. If the documentation does not support that those guidelines were met, the claim is counted as a total or a partial improper payment. The error is then categorized into one of the following categories: (1) No Documentation, (2) Insufficient Documentation, (3) Medical Necessity, (4) Incorrect Coding, or (5) Other. The MAC is then responsible for collecting the funds that were incorrectly paid to the provider.

Last Reviewed: 6/16/2022

The CERT program is comprised of two contractors. Each contractor has separate responsibilities. Examples of those duties are listed below:

1. The CERT Review Contractor (CERT RC) — NCI Information Systems, Inc.

  • Samples claims
  • Requests, receives and reviews all medical records
  • Images medical records
  • Performs quality control of those records
  • Delivers provider customer service
  • Offers education support
  • Compiles data
  • Maintains the CERT C3Hub

2. The CERT Statistical Contractor (CERT SC) — The Lewin Group, Inc.

  • Calculates improper payment rates
  • Designs sampling strategy
  • Maintains Live Data dashboard

Please visit CMS Comprehensive Error Rate Testing (CERT) for more information concerning these contractors.

Last Reviewed: 6/16/2022

Requested documentation can be sent to the CERT Review Contractor (RC) in any of the following ways. Please be sure to include the Claim Identification number (CID number) and barcoded cover sheet.

Via U.S. Mail

CERT Documentation Center
8701 Park Central Drive, Suite 400-A
Richmond, Virginia 23227

Via Fax to (804) 261–8100

  • Use the barcoded cover sheet as the only coversheet
  • Do not add your own cover sheet — this slows down the receipt and identification process
  • Send a separate fax transmission for each individual claim

Via Electronic Submission of Medical Documentation (esMD)

  • Include a CID# or Claim number and the barcoded cover sheet in your file transmission
  • Information on esMD 

Via CD

  • The images should be encrypted per HIPAA security rules
  • If encrypted, the password and CID# must be provided via email to CERTMail@nciinc.com or via fax to (804) 261–8100
  • Images can only be in TIFF or PDF format

Via Email Attachment

  • The email attachment(s) should be encrypted per HIPAA security rules
  • If encrypted, the password and CID# must be provided via phone to 888–779–7477 or via fax to (804) 261–8100
  • Attachments can only be in TIFF or PDF format

References

Last Reviewed: 6/16/2022

Respond to each request separately. You may receive multiple requests on the same beneficiary for the same or different dates of service. Attach the original bar-coded sheet to each individual set of records. When submitting the medical records, follow the instructions in the letter for submitting medical records. Each request has a CERT Claim Identification Number or CID. The CERT Review Contractor prefers to receive records via fax: (804) 261–8100.

Last Reviewed: 6/16/2022

There is no set time frame for the medical review by the CERT contractor.

Last Reviewed: 6/16/2022

If the CERT contractor determines that the claim was processed correctly, no notification occurs. If the CERT contractor's decision is to pay, deny, partially deny, downcode or up-code the claim, the CERT contractor notifies Palmetto GBA of the decision. Palmetto GBA will make adjustments to the previous reimbursement, and if the overpayment is greater than $10, we will notify you in writing to request a refund. The provider will also receive a CERT error letter from Palmetto GBA to explain the specific reason for assessing the error.

Last Reviewed: 6/16/2022

The provider compliance error rate measures the accuracy of claims when they are first submitted to the contractor. It is based on how the claims looked when they arrived before any edits are applied or reviews are conducted. The provider compliance error rate is a good indicator of how well the Medicare Administrative Contractor (MAC) is:

  • Educating the provider community
  • Processing the claims
  • Ensuring providers have prepared claims accurately for submission

Last Reviewed: 6/16/2022

The paid claims error rate is the percentage of total dollars the MACs erroneously paid or denied and is a good indicator of how claims errors impact the Medicare trust fund. This error rate includes paid and denied claims.

Last Reviewed: 6/16/2022

Compliance with the CERT process benefits providers by ensuring that claims are reimbursed appropriately, which prevents unnecessary denials and appeals, and may prevent additional medical review of providers.

Last Reviewed: 6/16/2022

Once you have logged into eServices, locate the eReview tab. If you cannot view this tab, you may not have the necessary permissions. Contact your provider administrator on the account to request access. From the eReview tab, select the eAudit subtab. This section currently features CERT contractor claim review and status information that is updated monthly.

Select CERT Claim Review Status from the Audit Type dropdown menu on the eAudit screen, it will automatically populate with a summary table of your CERT audit data by error code category.

  • The claim data table will list the type of error by claim and claims pending review by the CERT contractor
  • The claim data details table will allow users to see the claim line details for that audit error code category noted on the claim data table. There is also a definition of the line error code. Each of the items in the claim data details table can be expanded for extra details.

Last Reviewed: 6/16/2022