March 29, 2007
REVISED: CERT (Comprehensive Error Rate Testing) -- Third Party Documentation
During a CERT review, you may be asked to provide more information related to a claim you submitted, such as medical records or certificates of medical necessity, so that the CERT review contractor can verify that billing was proper. The CERT Documentation Contractor sends requests for this additional information via fax and/or postal mail. There are times when the response received might be one of the following:
- Patient was not seen on this date of service
- Patient not seen in this office
- Records are at the hospital, call them
In many cases, the patients were seen at a different facility. As a Medicare provider it is your responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary (in accordance with 42 U.S.C. 1320C-5 (a) (3) and 1833 of the Social Security Act). Providing medical records of Medicare patients to the Comprehensive Error Rate Testing (CERT) contractor is within the scope of compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Another situation where this occurs is with diagnostic tests, mainly labs and x-rays. The CERT contractor or Medicare asks the provider rendering the service – the lab or radiology practice – for the information. They may not have the diagnostic information from the primary/ordering physician, so their claim may be denied. It would be advantageous for all if primary/ordering physicians make certain to provide the diagnostic facility with the clinical information so the billing and documentation can be complete and the providers can be paid appropriately.
If you fail to submit the requested information in a timely fashion, the claim is deemed to be an error and a refund of the overpayment will be requested from the billing provider. As you can see, it is very important that supporting documentation is provided whenever it is requested by the CERT contractor.
If you have any questions, call CERT Customer Service at (301) 957.2380 between the hours of 8:00 AM to 6:00 PM EST.
