Comprehensive Error Rate Testing (CERT)
Since 1996, CMS implemented several initiatives to prevent improper payments. CMS' goal is to reduce payment errors by identifying and addressing billing errors concerning coverage and coding. The Comprehensive Error Rate Testing Program (CERT) is one of the programs created by CMS to assist in eliminating improper payments.
AdvanceMed has a contract with CMS to perform random audits of chart notes and medical reports to verify the accuracy of claims payment. If you receive a request from AdvanceMed, to eliminate the additional letter requests and follow-up calls, indicated below, from the contractors for the non-responder and Request for Additional Documentation requests, it is important to supply the requested information/documentation as soon as possible.
Request and Response Timeline
- Initial Record Request – 75 days to respond
- Day 0: Contact and/or send letter 1 via fax or mail
- Day 30: Contact and/or send letter 2 via fax or mail
- Day 45: Contact and/or send letter 3 via fax or mail
- Day 60: Contact and/or send letter 4 certified
- Day 76: If no records were received, full claim error assigned.
- Tech Stops (i.e. Requests for Additional Document [RAD]) – 15 days to respond
- Day 0–2: Contact and send letter 1 via fax or mail.
- Day 10–15: Contact and send letter via fax or mail, if requested
- Day 16: Claim placed back into review process.
- Medical Review Specialist (MRS) Letters – 10 days to respond
- Day 0: Contact and send letter 1 via fax or mail
- Day 11: Claim placed back into review process.
Communication Between Noridian and Providers
Noridian CERT Team provides the below provider communication regarding the CERT program.
Providers must submit initial medical records to CERT within 75 days of receipt of initial record request. If a provider has not responded to initial records request by day 40, Noridian will call provider
The CERT Contractor initiates a tech-stop when they have received the initial set of records; however, upon review, determined that key elements were missing. Review is placed on hold until provider provides additional documentation.
Providers have only 15 days to comply with CERT tech-stop request. If a provider has not responded to request by day 7, Noridian will make a reminder call to provider
Facility Error Findings Letter
Providers who receive a CERT error will also receive a Facility Error Findings letter explaining CERT error review findings and provider corrective action options* available. The letter should be used to educate all provider staff members associated with the CERT program (e.g. billers, compliance officers, medical records etc.)
- Letter Examples
- Insufficient, No Document, No Response Error Letter: Identifies a claim that has received a CERT error for insufficient documentation, no documentation, no response, or will be receiving such error
- Medically Unnecessary Service or Treatment Error Letter: Identifies a claim that has received a CERT error for medically unnecessary service or treatment, or will be receiving such error
- Provider Error Letter and Report (Quarterly): Quarterly report identifies CERT errors from a specific timeframe and assists facilities with tracking and trending of such errors. Typically, by the time a provider receives provider error reports, appeal timeframe has been exhausted. To avoid an appeal dismissal, due to late filing, providers should initiate any corrective action indicated within letter
If provider wants to appeal a CERT decision, the request should be initiated shortly after receiving the Facility Error Findings letter.
The letter includes CERT Claim ID (CID), Health Insurance Claim (HIC) number, Date of Service, patient's name, CERT reviewer comments, and lists provider's corrective action options
- *Provider corrective action options may include:
- Internal education
- Submission of additional documentation to CERT contractor (if before deadline)
- Submission of appeal (if before deadline)
To submit a CERT related question to Noridian Medicare Part A, follow the instruction on Contact Us with CERT Questions webpage.
Invalid or insufficient documentation will result in a denial or reduction of the claim payment so it is best to submit all information which supports the services rendered. Noridian has created multiple documentation request checklists which may assist you in compiling the documentation needed.
When replying to the request, photocopy each record (Medicare does not reimburse for copying medical records). All copies must be complete, legible and contain both sides of each page including the page edges. The Claim Identification Number (CID#) identifies specific requests.
- CMS CERT Team (Governs all CERT efforts)
- Admission Date and Statement Covers Period Billing
- CERT Initial Requests for Records vs. Requests for Additional Documentation
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- Inpatient Rehabilitation Facility (IRF) Services and Pre/Post-Admission Documentation
- Noridian Communications with Providers
- Spinal Fusions: Anterior vs. Posterior
- Take Action on CERT Determinations to Ensure Timely Appeal Submission
- Urinalysis Billing
- CMS Medicare Learning Network (MLN) Matters Special Edition (SE) 1236 - Documenting Medical Necessity for Major Joint Replacement (Hip and Knee)
Last Updated Oct 07, 2016
Follow standard appeals process and submit request to Noridian.
AdvanceMed - CERT Review Contractor
CERT Documentation Center
1510 East Parham Road
Henrico, VA 23228
CMS CERT Team
Mail Stop C3-09-27
7500 Security Blvd
Baltimore, MD 21244
Last Updated Oct 07, 2016