Requests, Response, Communication and Actions - JF Part B
Follow standard appeals process and submit request to Noridian.
AdvanceMed - CERT Review Contractor
CERT Documentation Center
1510 East Parham Road
Henrico, VA 23228
Phone: 443-663-2699 or 888-779-7477
CMS CERT Team
Mail Stop C3-02-16
7500 Security Blvd
Baltimore, MD 21244
CERT Requests, Response, Communication and Actions
Access the below information from this page.
- CERT Requests, Timeline and Noridian Communication
- Respond to a CERT ADR Letter
- Provider Corrective Actions
- Contact Noridian with CERT Related Inquiries
CMS has a contract with AdvanceMed to perform random audits of chart notes and medical reports to verify the accuracy of claims payment. If you are a provider who receives a request from AdvanceMed (CERT Review Contractor) to eliminate additional letter requests and follow-up calls, it is important to supply the requested information/documentation as soon as possible. These requests for records do not pose any Health Insurance Portability and Accountability Act (HIPAA) vulnerabilities. Beneficiary authorization is not needed to release information because authorization has already been given to release necessary medical information in order to process the claim.
MACs are responsible for adjudicating claims based on CERT reviews and educating providers on the findings and top trends identified. We accomplish this by assisting AdvanceMed with obtaining records, contacting providers with CERT review findings, and offer education to the affected providers.
Below are the requests sent by the AdvanceMed as well as the various provider contacts made by Noridian. Other informational and educational letters may be sent by the MAC periodically.
|Request||Days to Respond||Contact/Response Timeframe||Noridian Communication with Providers|
Initial Record Request
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
Non-Responder Contact - Providers must submit initial medical records to CERT within 45 days of receipt of initial record request. If a provider has not responded to initial records request by day 35, Noridian will contact the provider
Tech Stops and Medical Review Specialist (MRS) (i.e. Requests for Additional Document [RAD])
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
Tech-Stop/MRS Contact - The CERT Contractor initiates a tech-stop/MRS when they have received the initial set of documentation; however, upon review, determined that key elements were missing. A RAD is not a duplicate request for documentation. Do not disregard this request as the review has been placed on hold until the provider provides the additional documentation. Providers have only 15 days to comply with CERT tech-stop/MRS request. If a provider has not responded to request by day 7, Noridian will contact the provider (phone call and/or letter)
It is important providers comply and respond to these letters promptly. View Sample Request Letters on the CERT Provider Portal.
Notification of Findings
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.)
See the Provider Mailing Addresses and Points of Contact for CERT Requests webpage to learn more about the below.
- Update Primary Practice and/or Correspondence Address in PECOS
- Add an Alternate Address for Subsequent Request Correspondence
- Create a Point of Contact (POC) with AdvanceMed and/or with Nordian
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 Requirements checklists which may assist providers 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. Fax is the preferred method for submission.
- AdvanceMed - Receives and reviews submitted CERT documentation
- CMS CERT Team - Governs all CERT efforts
- Act fast (don't miss opportunity to submit initial or additional records to CERT)
- Internal education
- Implementation or improvement to internal controls or intake processe
Submission of additional documentation to CERT contractor (if before deadline)
- We encourage providers to submit his/her additional documentation back to the CERT review contractor when possible. If they receive sufficient supporting documentation, they will reverse their finding and Noridian will process the claim for payment based on the final CERT outcome.
Submission of appeal - A request must be submitted within the 120-day Redetermination timeframe. Timeframe begins on Remittance Advice (RA) date which contains the adjusted/denied CERT claim
- If a provider chooses to appeal a CERT decision, it must be submited shortly after receiving the "Facility Error Findings" letter from Noridian. This letter describes the specific CERT determination, is mailed to the designated CERT POC and its date corresponds closely with the RA date. CERT appeal requests follow the standard Redetermination request process.
Contact Noridian with CERT Related Inquiries
- See the Contact Noridian with CERT Related Inquiries webpage for instructions to submit such questions.
Last Updated Mon, 02 Jul 2018 07:07:28 +0000