The Comprehensive Error Rate Testing (CERT) program was initiated by CMS to achieve the agency’s mission to emphasize accountability, pay claims appropriately, and to provide a renewed focus on the customer. The program produces national, contractor-specific, and service-specific paid claim error rates, as well as a provider compliance error rate. The paid claim error rate is a measure of the extent to which the Medicare program is paying claims correctly. The provider compliance error rate is a measure of the extent to which providers are submitting claims correctly.
The program has independent medical reviewers periodically reviewing representative random samples of Medicare claims that are identified as soon as they are accepted into the claims processing system. The independent reviewers medically review claims that are paid; by contrast, claims that are denied are validated to ensure that the decision was appropriate.
There are two contractors who administer the CERT Program on behalf of CMS. The CERT Review Contractor selects random samples of claims from each Medicare claims processing contractor for medical review. For each claim selected, the CERT Documentation Contractor (CDC) requests medical records from the physicians and non-physician providers who billed for the services, tracks record receipts, and prepares the documentation for review. Using the medical record documentation received, the contractors verify that the services were billed correctly, and that the Medicare Administrative Contractor (MAC) decisions regarding the payment and processing of the claim(s) were accurate and based on sound policy. Claims that are billed, paid, or processed incorrectly are categorized as errors.
Use the following resources to learn more about the program:
- CERT Brochure
- CMS Main CERT Program Page
- CERT Website
- Signature Guidelines for Medical Review Purposes
- Medicare Claim Review Programs