Comprehensive Error Rate Testing Frequently Asked Questions

What is CERT?

CERT stands for the Comprehensive Error Rate Testing (CERT) Program. CERT was established by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claim payment in the Medicare Fee-For-Service program.

How does the process work?

The CERT Documentation Contractor (CDC) randomly selects processed claims, and sends a letter to the provider requesting specific documentation to support the services billed. The documentation you must submit is similar to what is required in response to an Additional Development Request (ADR). The CDC forwards the documentation to the CERT Review Contractor (CRC) who reviews the documentation, and determines if the payment decision made by Cahaba was correct. This data is then collected, and CMS generates reports to identify contractor’s error rates.

What information is sent to us when one of our claims is selected by CERT?

  • Information about the CERT process
  • Information about the selected claim
  • List of the documentation to send to CERT
  • Where to fax (preferred method) or mail the documentation
  • Timeframe for sending documentation
  • Name and telephone number of a CERT contact person if you have questions/comments
  • Bar coded cover sheet
  • Health Insurance Portability and Accountability Act (HIPAA) information  

What do the letters or requests for medical records look like?

You can view samples of the CERT letters Globe to indicate www link. online.

What should we do if our claim is selected for a CERT review?

  • Review the CERT Request for Medical Records to determine the documentation being requested
  • Keep the Request for Medical Records and the bar coded cover sheet on file
  • Gather all documentation requested in the letter, and any additional documentation that supports the coverage and medical necessity of all services billed for the dates of service indicated on the request
  • Photocopy each record. Make sure all copies are complete, legible, and contain both sides of each page
  • Place the bar coded cover sheet in front of the documentation
  • Submit the documentation within the requested timeframe to the CDC
    • Fax:(preferred method) 240-568-3092
    • Mail:
      CERT Documentation Office
      Attn: CID#: xxxxxx
      9090 Junction Drive, Suite 9
      Annapolis Junction, MD 20701

How long do we have to send in the requested information?

You have up to 75 days after the initial request letter to send in your documentation. It is suggested that you send your documentation as soon as possible. If your documentation is not received within 30 days of the request, the CDC will send follow-up request letters and may call you. Cahaba may also call you to ensure you respond to the requests. By responding promptly, you will eliminate additional letters and telephone calls.

What can we do to ensure our documentation is received timely?

  • Be alert to requests from the CDC
  • Designate a CERT point of contact for whom will be responsible for receiving the request letters and/or telephone calls and for ensuring they are responded to timely
  • Post a sample copy of the request letter where the mailed requests are likely to be received with instructions indicating to whom it should be routed
  • Alert staff responsible for answering the telephone about the CERT process and give them instructions indicating to whom the call should be routed
  • Make sure your main provider address and telephone number are correct as submitted on the provider enrollment form (CMS 855). If it is not correct, or if you have questions regarding this process, access the “Phone Us” page to obtain the telephone number for the  Provider Contact Center (PCC). 
  • For questions or comments related to the Request for Medical Records, you may call the CERT Customer Service line at (301) 957-2380

How can we ensure our CERT point of contact information is current and how can we make changes if needed?

There are several ways that you can change or update your CERT point of contact information:

Do we need the beneficiary’s authorization to release the information to the CERT contractor?
No. Medicare beneficiaries have already given authorization to release medical information in order to process claims. It is not a HIPAA violation to submit documentation to the CERT contractor.

Do we need to obtain all the documentation/ information from our associated providers?

Yes. It is the responsibility of the provider who is billing the services to respond to the request for medical records. If the medical records reside with a third party (e.g. clinics, labs, hospitals), you are still responsible for obtaining the documentation and sending them to CERT.

Who are the errors assessed to?

The errors are assessed to the Fiscal Intermediary (FI) and the provider who billed the services. When an error is determined, the claim is adjusted by the FI. Providers are notified of claims denied by CERT via their Remittance Advice (RA), or Electronic Remittance Advice (ERA)

How are the error reports published?

Reports are generated and are available from the CMS Web site. These reports produce a national paid claims error rate and error rates for various contractors, services, and provider types. The reports are available to the public at http://www.cms.hhs.gov/CERT/CR/list.aspGlobe to indicate www link.

What outcomes are expected from the program?

The CERT Program supports CMS’s primary objectives of ensuring that Medicare contractors are paying claims appropriately, and providers are billing medically necessary services correctly. The error results help identify the areas of greatest vulnerability to the Medicare program, and will assist in directing educational activities to reduce the error rates.  

What if we have additional documentation that we did not originally send with the request?

You may send in additional documentation to the CDC at any time, even if it is after the requested time frame. Be sure to include the bar coded cover sheet to identify the claim ID (CID) number on your documentation

Why would the CERT contractor consider my claim an error?

Errors may result for the following reasons:

  • No documentation errors

These errors result when the provider fails to respond to the request for medical records, or responds to the request untimely. In order to avoid these types of errors, be sure to respond within the timeframe indicated on the request. Keep provider contact information current and accurate.

  • Insufficient documentation errors -

The majority of errors are due to insufficient documentation, such as missing lab results, radiology reports, therapy minutes, or hospice election statements. In order to avoid these types of errors, be sure to submit all applicable information to support the services billed on the claim, and the information requested on the documentation checklist. You may need to contact the ordering physician’s office or third party entity to obtain all of the necessary documentation.

  • Medically unnecessary services or treatment errors -

Submit all applicable information that supports the medical necessity of the service and that it is payable according to Medicare guidelines.

  • Incorrect coding errors-

These errors result when the documentation submitted supports that either a different code, or different number of service units should have been billed. Be sure to follow the Healthcare Common Procedure Coding System (HCPCS) and ICD-9-CM Official Coding Guidelines. In order to avoid these types of errors, the documentation submitted must support the specific code billed. In addition, the documentation must accurately support the number of service units billed.

  • Improper documentation errors -

Ensure the documentation submitted is for the correct beneficiary and dates of service on the request.

What if one of our claims receives an error?

  • Cahaba will be required to adjust the claim.
  • The adjusted claim can be identified by an XXH type of bill on the RA/ ERA.
  • You should monitor claims for which documentation was submitted to the CERT contractor and review your RAs/ERAs.
    • If additional documentation is available, you may submit it to the CERT contractor at any time. The CERT contractor will re-review the claim with the additional documentation you submitted.
    • If no additional documentation is available, you have the same appeal rights under CERT that you would have under traditional Medicare. There are five appeal levels, beginning with the redetermination level.

What is a Tech Stop?

Once the CERT contractor receives the submitted documentation, it is reviewed to determine if the documentation is complete. If missing documentation is identified, such as the result of a lab, or a physician’s order, a letter, called a “Tech Stop”, will be sent to the provider requesting the missing documentation. You will have 15 days to respond to the Tech Stop and submit the missing documentation. Be sure to send the bar coded cover sheet to identify the claim ID (CID) number to which your documentation is being sent. After 15 days, if no additional information is sent, the CERT contractor will review the claim using only the original documentation submitted. Often, errors are assessed due to the insufficient documentation. A sample of a Tech Stop letter can be found at: http://www.certcdc.com/certproviderportal/sampleletters/techstop-en.pdfGlobe to indicate www link.

Where can I get more information about the CERT program?

http://www.cms.hhs.gov/CERT/ Globe to indicate www link.
http://www.certcdc.com/certproviderportal/Globe to indicate www link.

Who can I contact if I have questions regarding the CERT program?

Provider Contact Center: 866-539-5598

Page last updated: September 30, 2008

Curved image to open content area.