Comprehensive
Error Rate Testing (CERT)
The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to produce national, contractor-specific, and service-specific paid claim error rates. The program has independent reviewers who periodically review random samples of Medicare claims. The independent reviewers medially review claims that are paid and claims that are denied to ensure the decision was appropriate. CERT was implemented in order to achieve goals of the Government Performance and Results Act of 1993, which sets performance measurements for Federal agencies.
Each month, the CERT contractor selects a random sample of claims processed by each Medicare contractor. They then request medical records, Certificates of Medical Necessities, and supporting documentation from the provider of the service to verify services billed were delivered, medically necessary, and the appropriateness of claims processing procedures. If contacted, you will be provided with the details regarding the needed information and how to submit it.
When no medical records or supporting documentation are received, a denial decision is made which ultimately results in a request for refund from the provider if the claim had been paid originally. These claims may be appealed through normal channels at the DME MAC.
When records/documentation are received, the CERT contractor's medical review staff (includes nurses, physicians, and other qualified healthcare practitioners) performs a complete review of the claims. If documentation fails to support the item(s) billed, an error is called. A refund will be requested from the provider. Documentation that supports the medical need will result in no further action needed by the provider.
Additional information about CERT may be found at the CMS Web site, www.cms.hhs.gov/cert or through our Web site, www.cignagovernmentservices.com.
About CERT/HIPAA
CERT Sample Letters
- Initial Request For Medical Records
- Second
Request For Medical Records
- Third
Request For Medical Records
- Final
Request For Medical Records
- Tech
Stop Request For Medical Records
