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CERTs

Comprehensive Error Rate Testing Contractors (CERTs)

CERTs calculate and monitor the accuracy of Medicare fee-for-service (FFS) claims submitted to MACs, carriers and DME regional carriers, to gain insights into the causes for errors. Each year, CERTs evaluate a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. Claims selected for CERT review are subject to potential post payment denials, payment adjustments, or other administrative or legal actions, depending on the result of the review. CMS publishes the results of these reviews annually.

There are three types of CERTs: the CERT Review Contractor (RC), the CERT Documentation Contractor (DC), and the CERT Statistical Contractor (SC).  The current DC is Livanta LLC., responsible for reviewing selected claims and associated medical record documentation. The current RC is NCI AdvanceMed Corp., responsible for requesting and receiving the medical record documentation from providers. The current SC is The Lewin Group, responsible for randomly selecting a statistically valid sampled claim.

When CERTs request provider documentation for services billed, the provider must respond within 45 calendar days from the request. Providers also are required to respond to all requests for additional information within the time-frame outlined in a request letter. CERTs focus on the following five error categories:

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Providers have the same appeal rights under the CERT program as they would have under traditional Medicare. For more information, you can visit the CMS site here.

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