Last Modified: 9/22/2020
Location: FL, PR, USVI
Business: Part A, Part B
The Centers for Medicare & Medicaid Services (CMS) established the Comprehensive Error Rate Testing Program (CERT) to measure the accuracy of claim payments under the Medicare program. Under this program, CMS calculates a national paid claims error rate, and a contractor specific error rate. Medicare contractors use CERT findings to improve the quality and accuracy of claims submission, processing and payments.
CMS contracts with AdvanceMed, the CERT review and documentation contractor that is responsible for sampling, requesting and reviewing the selected claims and associated medical record documentation.
The CERT program methodology includes:
• A random sampling of paid claims submitted in a specified timeframe
• A request for medical documentation from providers submitting the claims
• A review of medical documentation to determine if claims meet medical necessity, coding and billing requirements
A request for medical records from the CERT contactor alerts you that your claims have been selected as part of the random sample and will include the following:
• Bar coded claim attachment cover sheet
• List of medical documentation requested
• Claims attachment pull list
• Instructions on how to submit the documentation
All initial additional documentation request (ADR) letters are sent to the address on file with the Provider Enrollment, Chain and Ownership System (PECOS). Information on how to provide address updates to First Coast, please see MLN Matters® article SE1617
or the CERT provider website at https://www.certprovider.com/
What you need to do
• Provide specifically requested documentation and any other information supporting medical necessity
• If necessary, procure any required information from third party providers
• Keep enrollment information current, notify First Coast of changes to mailing addresses, phone numbers, practice locations, etc., within 30 days of the change
What you need to avoid
• If you fail to respond to documentation requests it will result in an automatic overpayment and you will receive a request to refund associated payments
• Submitting incomplete and inaccurate documentation will result in claim denials and losses of revenue
Instructions for submitting requested medical records documentation
The requested documentation is due as soon as possible after receipt of the initial request. Claims will be denied if the requested information is not received within 75 days. Please adhere to the following directions if you are mailing the requested documentation:
• Send the specific records listed on the bar coded cover sheet to support the services of each claim identified on the medical records/documentation pull list
• Photocopy each record. Make sure all copies are complete, legible and include both sides of each page
• Place the bar coded cover sheet in front of the medical records/documentation being submitted for review
If you need to submit medical records or passwords associated with medical records you may send to CERTmail@nciinc.com
When you have questions about a request for medical records or other assistance you may send the request to CERTprovider@nciinc.com
CMS issued change request (CR) 6698 to clarify for providers how Medicare claims review contractors review claims and medical documentation submitted by providers. The previous language in the Medicare program integrity manual (PIM) required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. CR6698 updates these requirements and adds language for E-prescribing.
Signature requirements resources
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.