CERT Review Process

Initial Documentation Requests

The Comprehensive Error Rate Testing (CERT) review contractor (RC) selects a random stratified sample of claims submitted to each Medicare Administrative Contractor (MAC) and physically mails the supplier an initial request letter for supporting documentation. Each claim reviewed receives a unique seven-digit claim identifier (CID) for tracking purposes. The request contains the following:

  • Letter
  • Claim Information
  • Barcoded Cover Sheet

The CERT RC reviews the submitted documentation to verify:

  • Billed services were provided
  • Billed items were delivered
  • Medical necessity was supported
  • MAC claims processing procedures were accurate

Providers and suppliers should submit all the necessary documentation supporting payment for the claim submitted to Medicare. Supporting documentation may include, but is not limited to:

  • Order
  • Refill request
  • Proof of delivery
  • Any additional supporting documentation

Initial Request Schedule

The CERT RC posts their initial request schedule on the C3HUB where sample letters may also be found. The schedule is contingent on the provider or supplier’s submission of medical records.

The table below shows the CERT review timeframe and the provider or supplier compliance expectations.

Initial Request Schedule

Day CERT RC Action Provider Deadline
0 Send first letter requesting documentation Send CERT RC the documentation within 45 days from initial letter
21-29 Telephone contact to follow-up on request and/or offer assistance Send CERT RC the documentation within 45 days from initial letter
30 Send second letter requesting documentation Send CERT RC the documentation within 15 days from second letter
35-44 Telephone contact to follow-up on request and/or offer assistance Send CERT RC the documentation within 15 days from second letter
45 Send third letter requesting documentation Send CERT RC the documentation immediately
49-59 Telephone contact to follow-up on request and/or offer assistance The response is overdue, and documentation is required immediately
61 Claim is counted as non-response error and is subject to overpayment recovery by the Medicare Administrative Contractor (MAC) Send CERT RC the documentation or contact Noridian with any questions

Subsequent Request Schedule

The CERT RC may identify the need for additional information while conducting medical review of the documentation received. A new additional documentation request will be issued to obtain the specific item of missing documentation.

The table below shows the CERT review timeframe and the provider or supplier compliance expectations.

Subsequent Request Schedule

Day CERT RC Action Provider Deadline
1-9
  • Send first letter
  • Telephone contact to follow-up on request and/or offer assistance
 Provide the missing documentation
10-15
  • Send second letter
  • Telephone contact to follow-up on request and/or offer assistance
 Provide the missing documentation
16
  • Claim back in review process
  • Claim review resumes, even if no documentation is received
 Provide the missing documentation

Record Request Response

The CERT RC sends record requests to the Correspondence Address in the Provider Enrollment Chain and Ownership System (PECOS). Providers and suppliers are encouraged to verify this address to ensure timely receipt of CERT communications. A response to the CERT RC’s record request is required.

It is the supplier's responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary.

This instruction is in accordance with:

  • 42 U.S.C. Section 1320C-5 (a) (3)
  • Section 1833 of the Social Security Act
  • Health Insurance Portability and Accountability Act (HIPAA)

Failure to produce the documentation will count as an error in the calculation of the CERT program error rate. The Medicare contractor will recoup any paid claim found in error by the CERT RC and an overpayment request will be generated.

Documentation Submission

The CERT RC's C3HUB website's left-hand navigation offers a "Submit Records to CERT" link which advises of five different documentation submission options.

  • Send specific records listed on the barcoded cover sheet
  • Ensure all copies are complete, legible, and include both sides of each page
  • Place the barcoded cover sheet in front of the documentation

Review Findings

The CERT review status can be found by using the "Claim Status Search" from the left-hand navigation on the C3HUB.

  • Enter the Claim Identifier (CID)
    • Review Status: Current status of the CID
    • Documentation Status: Most recent CERT documentation request or receipt

To view a specific CERT review finding:

  • Log into the Noridian Medicare Portal
    • Go to Claim Status
    • Go to CERT Inquiry tab
    • Enter required fields
    • Enter CID
    • Click Submit Inquiry

To view all CERT review findings:

  • Log into the Noridian Medicare Portal
    • Go to Claim Status
    • Go to CERT Inquiry tab
    • Enter required fields
    • Leave CID field blank
    • Click Submit Inquiry

Contact Us

For any questions, please contact the Noridian CERT team.

Last Updated Mar 05 , 2025