The Review Process
Incorrect or No Documentation:
The Comprehensive Error Rate Testing (CERT) contractor reviews 200 randomly chosen claims processed by CIGNA Government Services each month. Providers may get as few record requests as one per year or as many as 2 or more per month.
Please Note:
- Each record request not responded to will be denied in total
- Each incomplete record submitted will be denied in part or in total
- Each record request from CERT requires a provider response EVEN IF the provider does not have the record. If no response is received by CERT, the claim will be denied.
*Providers have appeal rights within the CERT process
CERT Review of Records:
The medical review specialists at the CERT contractor will review each claim and determine the following:
- Does the service fit a Medicare benefit category
- Is the service statutorily excluded
- Is the service medically reasonable and necessary
- Is there documentation to support the service was performed
- Is the service coded and billed correctly
