Prevent a No Documentation CERT Finding

Be sure to provide the CERT contractor with the applicable documentation necessary to avoid a CERT finding for error code 16 - No documentation was received, or no documentation related to the claim line under review was received from the provider.

Reasons for this finding may be caused by the below responses. This is not an all-inclusive list.

  • No record of this patient in our system
  • No records for date of service requested
  • Patient was seen at facility "A", not our office
  • Check with "Said" facility as we have no record of this patient

The CERT contractor sends the request for records to the billing provider. Per Medicare contractual obligation, it is his/her (billing provider) responsibility to supply all requested documentation to support the billing, coding, and medical necessity of the claim billed under his/her Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI). In some cases, he/she must contact the ordering/referring provider to obtain additional documentation required to support the claim billing.

Provider cooperation is a legal requirement as outlined in the Social Security Act, the law governing Medicare. Section 1842(p)(4) of the Act mandates that: In case of an item or service…ordered by a physician or a practitioner…but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.

If the billing provider does not have and is unable to supply the appropriate documentation to support the service billed, a claim should not be submitted to Medicare for reimbursement.

View the Provider Mailing Addresses and Points of Contact for CERT Requests webpage for information on maintaining a current Point of Contact.

Last Updated Fri, 06 Oct 2017 10:56:47 +0000