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What is CERT?

CERT stands for "Comprehensive Error Rate Testing". It was first developed by CMS in (1996 to measure Medicare FFS Improper Payment Rate) for the purpose of reducing costs associated with improperly completed and improperly paid Medicare claims. (It was later amended to comply with Improper Payment information Act of 2002 and again amended by Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012)

CMS has contracted with (Advance Med) to oversee the CERT process for Jurisdiction C DME MAC. The CERT contractor randomly requests and audits approximately 4,000 claims per year from Jurisdiction C. At that time they also receive the provider address listed in the system so that they can request the record for review. CERT will send up to four letters to the provider requesting the records, one every 20 days or so. Failure to respond to a CERT request for documentation may result in an error.

The medical review specialists employed by the CERT contractor review each claim and determine the following:

Twice a month the CERT contractor sends a file to CGS that includes all the claims found to be in error. CGS adjusts the claims based on whether the error resulted in an overpayment or underpayment. The provider will receive a Remittance Notice for each adjustment made. CGS will also request refunds on errors that resulted in overpayments and will issue additional payment if claims are underpaid.

If an error is not found after the claim is reviewed by the CERT contractor, no response will be sent to the provider. The status of any claims sent to the CERT contractor can be checked by accessing the CERT Claim Identifier Tool.

If the provider disagrees with a CERT initiated denial, the decision may be appealed. The same Medicare guidelines for the appeals process at CGS apply to the appeals process for CERT initiated denials. All appeals for CERT initiated denials are processed through CGS.

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