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Corporate

09/30/2011

Comprehensive Error Rate Testing (CERT) Program

The Centers for Medicare & Medicaid Services (CMS) has requested that CGS publish the following information to alert and educate providers about importance of CERT letter and what procedure providers should take once receiving a CERT letter.

The CERT contractor was awarded a contract by CMS to determine the national, contractor specific, benefit category, and provider type paid claim error rates.

As a Medicare Program Safeguard Contractor (PSC) and in accordance with Sections 1816 and 1842 of the Social Security Act, the CERT contractor will request Medicare claim attachments and medical records from providers and/or suppliers of Medicare services.

Once a provider receives a CERT - Request For Medical Records letter, a provider should respond with the requested information within 75 days. If the requested information is not received within the 75 days, the claim will be adjusted based on the information on hand which could lead to a claim denial or reduction in payment. Providers may receive additional letters, for example, Second Request, Third Request, Final Request and the Office of Inspector General (OIG) Final Request.

To view or print a copy of the sample letter in English or in Spanish, select one of the PDF documents below.


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