Last Modified: 5/9/2019
Location: FL, PR, USVI
Business: Part A, Part B
Q: Will First Coast’s medical review department request additional documentation from providers during the CERT process?
A. The CERT contractor will request medical records that support services rendered on randomly-selected claims. The CERT contractor reviews the medical records and determines whether the claims were billed and paid in accordance with Medicare guidelines. If CERT errors are assessed due to “insufficient documentation” or “no response to documentation request”, First Coast may attempt to procure additional documentation from the provider. First Coast will review documentation for completeness and will fax them to the CERT contractor, which may result in an error being removed or payment being recouped.
, Medicare Program Integrity Manual, Chapter 12, Section 12.3.8
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