CERT Program Overview

The CERT Program calculates the paid claims error rate for Medicare claims submitted to Carriers, Durable Medical Equipment Regional Carriers, and Fiscal Intermediaries. CMS receives in excess of 2 billion claims per year. CERT randomly selects a statistical sample of these claims for review to determine whether the claims were paid properly. The CERT Program uses two contractors to accomplish this work: the CERT Review Contractor and the CERT Documentation Contractor.

The CERT Review Contractor is responsible for reviewing the selected claims and associated medical record documentation. The CERT Documentation Contractor is responsible for requesting and receiving the medical record documentation from providers.

When submitting records for review:

• Please be sure documentation submitted is legible
• Please submit records for all dates of service on the claim
• Please ensure that the medical records submitted provide proof that the service(s) was ordered by the MD and rendered. Also provide justification to support the medical necessity

For medical record requests received from the CERT Contractor, please complete the following steps:

• Photocopy the requested record as identified in the CERT contractor request
• Submit the bar coded sheet with a copy of the medical records or cover sheet with the CID #
• Preferred method of receiving records is via fax at 240-568-6222
• If unable to fax – records should be mailed to the CERT Documentation Office