CERT Inquiries and Solutions - JA DME

Q1. How can suppliers verify which address CERT letters are being mailed to?
A1. Suppliers may check their current address and contact information through the CERT Provider website.

Q2. If a supplier wants to make an address update, how should that be done?
A2. Effective April 24, 2017, if a provider or supplier wishes to change an address on file with CERT, an update to PECOS must be made. This necessary change was implemented so addresses are consistent throughout CMS. See CMS Medicare Learning Network (MLN) Matters (MM) Special Edition (SE)1617 - Timely Reporting of Provider Enrollment Information Changes for additional information. Updates can be made using the CMS-855S form.

Q3. What documentation must a supplier include when submitting a CERT appeal?
A3. All prescriptions, all progress notes, Certificates of Medical Necessity (CMNs)/DME Information Forms (DIFs), all other pertinent documentation that may support medical necessity.

Q4. When faxing documentation, how can a supplier be sure the CERT Documentation Contractor received it?
A4. Suppliers are reminded to ensure their fax was successfully transmitted by verifying the confirmation on their end. The CERT Documentation Contractor sends confirmation of the receipts of faxes whenever possible. The fax confirmation however, does not attest to the quality of the record nor does it guarantee the legibility, or completeness of the documentation received via fax. The CERT Documentation Contractor IS NOT ABLE TO fax a confirmation in the following situations.

• If there is a block on the suppliers fax number,
• If the phone number has an extension (It is possible that the confirmation will go to the main number, but may never make it to the proper party.),
• If there is line noise or bad connections,
• If color fax is being sent. Color faxing is not supported by the CERT Documentation Contractor,
• CERT Documentation Contractor modems are set to respond after two rings. If the supplier's fax machine hangs up after two rings, the CERT Documentation Contractor will not receive the fax,
• The supplier's fax machine is busy or not set up to receive. Note: fax confirmation will only be sent after the CERT Documentation Contractor Quality Assurance personnel releases the document(s) to Quality Control.

Q5. What is the purpose of the Medicare CERT program?
A5. CERT is a program integrity activity that CMS established to monitor the accuracy of claims that are paid for the Medicare Fee-For-Service program.

Q6. Why are suppliers required to send proper documentation to the CERT Documentation Contractor as soon as possible?
A6. By sending the proper documentation, this will ensure that a proper review is conducted and may eliminate the possible denial and/or reduction of your payment on this previously paid claim.

Q7. If a supplier is selected for a CERT review, what should they do?
A7. Suppliers will receive a request letter that includes all of the information needed to process the request from the CERT contractor. Requests for records from the CERT contractor do not pose any Health Insurance Portability and Accountability Act (HIPAA) vulnerabilities and must receive prompt attention. Respond to all requests for information from the CERT contractor within the timeframe allowed.

Q8. What documentation should providers send to the CERT Documentation Contractor?
A8. Suppliers should send the specific records listed on the Bar Coded Cover Sheet to support the services of each claim identified on the Medical Records/ Documentation Pull List. The responsibility for obtaining the correct documentation from the physician for the services rendered falls onto the supplier to ensure this is sent to the CERT contractor. When responding to the request from CERT, suppliers must submit all sufficient medical records pertaining to the services provided.

Q9. Is a supplier required to have the beneficiary's authorization to release the information to AdvanceMed or the CERT Documentation Contractor?
A9. No. Medicare patients have already given authorization to release necessary medical information in order to process claims.

Q10. There are some instances where not all the documentation is at one office, thus making the service seem unreasonable. Are suppliers required to obtain all the information from the outsourced/associated suppliers/providers? 
A10. Yes. When responding to the request from CERT, suppliers must submit all sufficient medical records pertaining to the services provided. Some of the CERT denials are because not enough information was submitted in the original request. Often, the ordering physician's original order is the missing documentation.

Q11. What can providers do if they have lost records due to flooding, etc.?
A11. Providers may obtain an Attestation Form from the CERT Provider website. After validation of the facts, the claim is pulled from the sample and another claim is selected as a replacement. The claim that is pulled is not considered a "no-documentation" error.

Q12. How does the CERT Documentation Contractor want the information presented to them?
A12. When replying to the request, photocopy each record. Make sure all copies are complete, legible and contain both sides of each page including the page edges. Send the completed records to the following location. Note: Fax is the preferred receipt method.

Q13. What is a CID#?
A13. The Claim Identification Number identifies specific requests.

Q14. What is the significance of the barcode sheet?
A14. The barcode sheet is another way of identifying a claim selected in the CERT program. Place the bar coded cover sheet in front of the medical records/documentation being submitted for review. Submit multiple records with the corresponding bar coded cover sheet as the separator page.

Q15. What are the time frames for submitting documentation to the CERT Documentation Contractor?
A15. The CERT Documentation Contractor will send the first request for documentation by fax. The second letter will be sent on day 30 from date of issuance of the letter and the third letter will be sent on day 45. Suppliers have up to 75 days after the initial letter to send in the documentation. If there is no response, CERT will review the provided information. Invalid or insufficient documentation will result in a denial or reduction of the claim payment.

Q16. Why are suppliers required to send proper documentation to the CERT Documentation Contractor as soon as possible?
A16. By sending the proper documentation, this will ensure that a proper review is conducted and may eliminate the possible denial and/or reduction of your payment on this previously paid claim.

Q17. How many calls and letters is the CERT Documentation Contractor required to make or send out?
A17. They are required to make up to three phone calls and send out up to four requests for medical records letters to suppliers to secure medical documentation in support of the claim. Noridian will place two reminder phone calls for documentation requests and one follow-up call for Request for Additional Documentations.

Q18. What if a supplier receives a Tech Stop letters notifying them that a stop has been placed on the CERT review until additional documentation is provided? Is there a time limit for responding to a Tech Stop?
A18. Yes. The time frame is 15 calendar days from the date of the Tech Stop letter.

Q19. What does the CERT Documentation Contractor do with responses such as "not our patient" and "wrong date of service?"
A19. These responses are sent to the Problem Resolution Office (PRO). PRO specialists research the claim by contacting the originating Medicare contractor to obtain a copy of the original claim for review.

Q20. What do suppliers risk by not responding to the CERT Documentation Contractor request?
A20. If the requested information is not submitted in a timely fashion, an "error" is registered against the Medicare contractor. These errors have a corresponding negative impact on the other error rates that are calculated under the CERT program.

It is imperative that suppliers respond to the request. 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 second or third party (physician office, hospital, nursing home, etc.), as necessary. Providing medical records of Medicare patients to the CERT contractor is within the scope of compliance with HIPAA.

Q21. What if a claim is determined by CERT to have been paid incorrectly?
A21. An overpayment (or underpayment) will be assessed. Overpayments will be recouped for those claims that the CERT program determines were paid incorrectly. The Medicare contractor will pursue overpayment recoupment for these undocumented services.

Q22. Is there a website where suppliers can go to for more CERT information?
A22. Suppliers may visit the CMS CERT website or the CERT Provider website