CERT Review Process - JA DME

Request for Documentation

The Comprehensive Error Rate Testing (CERT) Review Contractor, Empower AI, Inc., selects a random sample of claims submitted to each Medicare contractor monthly. Suppliers with claims selected for review will receive a request for supporting documentation, via mailed letter, from Empower AI, Inc. These documents will be reviewed in order to verify that the services billed were delivered and medically necessary and that the claims processing procedures were appropriate. Suppliers should submit all the necessary documentation supporting payment for the item or service they billed to Medicare. Supporting documentation may include, but is not limited to: an order, refill request, medical records, any additional supporting documentation, and a proof of delivery.

The CERT Documentation Contractor will send an initial request letter to each supplier. The request, with the official CMS logo, will contain the following: Request letter, Claim Attachment Cover Sheet, Medical Records/Documentation Pull List, and Instructions for Submitting Requested Medical Records/Documentation sheet containing the list of the medical documentation requested and contact information. If Empower AI, Inc. does not receive the requested documentation within 45 days of the initial letter, it will be followed by a series of letters and phone calls to the supplier. Samples of these letters are available on the CERT Provider website.

Schedule of CERT Calls and Letters

• Day 00: Contact and /or letter via fax/ or mail
• Day 21: Telephone contact to follow-up on request and/or offer assistance
• Day 30: Contact and /or second letter via fax/ or mail
• Day 35: Telephone contact to follow-up on request and/or offer assistance
• Day 45: Contact and /or third letter via fax/ or mail
• Day 49: Telephone contact to follow-up on request and/or offer assistance
• Day 60: Contact and /or fourth letter via fax/ or mail
• Day 76: Score claim as an error 99 on the Claim Status Website

While conducting medical review of the documentation received, the medical review specialist may identify the need for additional information. A new additional documentation request will be issued to obtain the specific item of missing documentation. The response time for this second request is shorter. The CERT Review Contractor follows this schedule:

Subsequent Request Schedule

• Day 01: Send letter 1.
• Day 01: Telephone contact to follow-up on request and/or offer assistance.
• Day 10: Send letter 2.
• Day 10: Telephone contact to follow-up on request and/or offer assistance.
• Day 16: Claim back in review process.

DME suppliers are encouraged to verify their contact information for medical records or compliance staff on file with the CERT contractor is accurate and up-to-date. Contact information should include, but is not limited to, supplier name, National Provider Enrollment (NPE) number and/or National Provider Identifier (NPI), physical street address, city, state, and zip code. Post Office (PO) Box addresses are discouraged because the CERT Documentation Contractor is unable to send Certified Return Receipt Requests when required for Medical Request Letters.

To verify current contact information, go to the CERT Provider website and click on the "Confirm Address" option on the top of the page. On the "Confirm Address" page, enter a valid Contractor ID and the NPE or NPI number to initiate a search for the contact information.

Responsibility to Respond to Requests

It is imperative that providers respond to the request. A response is required even if records for the sampled beneficiary dates of service cannot be provided. In accordance with 42 U.S.C. Section 1320C-5 (a) (3) and Section 1833 of the Social Security Act, as a Medicare provider, suppliers must provide documentation and medical records to the CERT contractor upon request to support claims for Medicare services. It is the supplier's responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary. Providing medical records of Medicare patients to the CERT contractor is within the scope of compliance with the Health Insurance Portability and Accountability Act (HIPAA).

If the requested documentation is not received within the requested time period, the CERT Documentation Contractor will assume the services on the claim were not rendered. Failure to produce the documentation will count as an error in the calculation of the CERT program error rate and will result in the computation of an overpayment. The Medicare contractor will pursue overpayment recoupment for these undocumented services.

Submitting Documentation

The preferred method for submission of medical records/documentation is via fax.

When faxing, please adhere to the following directions.

• Send specific documents listed on Bar-Coded Cover Sheet to support services of each claim identified on Medical Records/Documentation Pull List.
• Place bar-coded cover sheet in front of medical records/documentation being submitted for review. Submit multiple records with corresponding Bar-Coded Cover Sheet as separator pages.
• Be sure all pages are complete, legible and include both sides and page edges, where applicable.

If unable to fax documents, contact the CERT Documentation Office.

When mailing requested letters, please adhere to the following directions.

• Send specific records listed on Bar-Coded Cover Sheet to support services on claim identified on Medical Records/Documentation Pull List.
• Photocopy each record. Be sure all copies are complete and legible; include both sides of each page, including page edges.
• Place bar-coded cover sheet in front of medical records/documentation being submitted for review. Submit multiple records with the corresponding Bar-Coded Cover Sheets as separator pages.