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Program Comparison: Medical Review, CERT and Recovery Audit

The table below summarizes the similarities and differences between CGS's Medical Review Program, the Comprehensive Error Rate Testing (CERT) Program, and the Recovery Audit Program

  Medical Review CERT Recovery Audit
Providers Impacted All Medicare Fee-for-service (FFS) providers All Medicare FFS providers All Medicare FFS providers
Medicare Contractor Medicare Administrative Contractors (MACs) (i.e. CGS) CERT Review Contractor CERT Documentation Contractor Medicare Recovery AuditorsExternal PDF
Claims Impacted/ Number of Claims Selected Targeted claim review; numbers vary Random sample; limited numbers Widespread or targeted claim review; numbers vary
Prepayment Edit Yes No No*

* Some prepayment review in limited demonstration states only.
Postpayment Review Yes, possible Yes No – if clear payment error
Yes – if likely payment error
Provider response/action required Submit medical documentation within 30 days of additional development request (ADR) Submit medical documentation within 75 days from receipt of CERT letter Submit medical documentation within 45 days of date of letter (or request an extension)
Right to Appeal Yes Yes Yes

Additional Resources:

Reviewed: 11.30.21

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