Comprehensive Error Rate Testing (CERT) Question and Answer Fact Sheet

The Comprehensive Error Rate Testing (CERT) process created a way for the Centers for Medicare & Medicaid Services (CMS) to look at the accuracy of claims processed by all Medicare Administrative Contractors (MACs). The CERT contractor reviews a random sample of processed claims to determine if there has been an improper payment. An improper payment may have been made if a claim should have been fully or partially denied, or paid at a different level based on the submitted documentation. 

There are two contractors who comprise the CERT program. The CERT Statistical Contractor (CERT SC) and the CERT Review Contractor (CERT RC). The CERT SC is administered by The Lewin Group, Inc., who designs how the claims are sampled and calculates the improper payment rates. The CERT RC is administered by Empower AI, Inc. The CERT RC's function is to request, maintain and review sampled medical records to determine if the claims were appropriately paid. Once the reviews are completed for a specific period, the CERT SC calculates an improper payment rate for claims that were either overpaid or underpaid in error. This is referred to as the "improper payment rate." The CERT contractors are not part of Palmetto GBA.

An improper payment is a payment that should not have been made or a payment made in an incorrect amount. Both overpayments and underpayments are considered improper payments. These may include: 1) Payments to an ineligible recipient; 2) Payments for an ineligible service; 3) Duplicate payments; 4) Payments for services not received; or 5) Payments for an incorrect amount. Improper payments are a good indicator of how claim errors impact the Medicare trust fund.

The CERT contractor chooses a random sampling of processed claims from each MAC, requests medical records and reviews them to determine if an error in payment was made. The samples include claims that were both paid and denied by the MAC. After the claims within a specific period are reviewed, an improper payment rate is determined for each MAC.

Yes. The CERT process is a federally mandated program. Non-submission of medical records will result in a denial of all services billed on the claim. Please refer to MLN Fact Sheet Medical Record Maintenance & Access Requirements (PDF) for more information about documentation maintenance and access requirements for billing services to Medicare patients.

Compliance with the CERT process ensures the appropriate reimbursement of claims, preventing unnecessary denials and appeals, and reflecting a positive impression of the provider community by establishing a low payment error rate. Compliance with the CERT process may also prevent additional medical review.

Providing medical records of Medicare patients to CERT is within the scope of compliance with HIPAA. Resource: MLN Fact Sheet Collaborative Patient Care is a Provider Partnership (PDF).

The letter contains specific information on the CERT process, HIPAA compliance, a listing of documentation to submit (if additional documentation is requested), where and how to submit the documentation, timeframe for responding to the request, claim information, and an original barcoded cover sheet. Please note that the requested documentation is not all-inclusive; the provider should respond with all documentation necessary to support the medical necessity of the services billed and to support the billed services were provided. If applicable, an authenticated or intent to order the billed services should also be submitted with the documentation. A sample of the request letters can be viewed on the C3HUB portal under the section titled “Sample Request Letters.”  

Respond to each request separately. The provider may receive requests for several beneficiaries or just one. However, multiple requests for the same beneficiary and the same date of service may also be received. Even if you have already submitted the documentation once for that beneficiary, respond again. Attach the barcoded cover sheet every time medical records are submitted. This cover sheet has a claim identification (CID) number and instructions on how to submit the documentation. A second request for the same patient and date of service should be carefully reviewed to determine if there was missing information from the first response, or if new information is being requested. CERT prefers to receive records via fax.

The CERT Contractor sends follow-up or subsequent record requests when a response was received to the initial request, but certain required elements of the documentation are still missing. (For example, not all dates of service submitted, missing physician order, or a signature attestation is needed.) Be sure to closely review the CERT letter for details regarding what documentation is still needed.

• Via U.S. Mail

CERT Documentation Center
8701 Park Central Drive, Suite 400-A
Richmond, VA  23227

• Via Fax to (804) 261–8100
  • Use the barcoded cover sheet as the only coversheet; do not add your own cover sheet
  • Send a separate fax transmission for each individual claim
• Via Electronic Submission of Medical Documentation (esMD)
  • Include a CID# or claim number and the barcoded cover sheet in your file transmission
  • Information on esMD can be found at www.cms.gov/esMD 
  • For questions about esMD please contact: esMDBusinessOwners@cms.hhs.gov
• Via CD
  • Must contain only images in TIFF or PDF format 
  • The images should be encrypted per HIPAA security rules. Once encrypted, the password and CID# must be provided via email to CertMail@empower.ai or via fax to (804) 261–8100.
• Via Email Attachment
  • Must contain only attachments in TIFF or PDF format 
  • The email attachment(s) should be encrypted per HIPAA ecurity rules. Once encrypted, the password and CID# must be provided via phone to 888–779–7477 or via fax to (804) 261–8100.

Providers should contact CERT directly at 888–779–7477. You may also email CERT at certprovider@empower.ai. Be sure to include only the CID and do not include PHI. For questions not related to submission of records, call Palmetto GBA's Provider Contact Center.

• Jurisdiction J (JJ): 877–567–7271
• Jurisdiction M (JM): 855–696–0705
• Railroad Medicare: 888–355–9165

The initial letter requesting records asks providers to submit the medical records within 45 days of the initial letter date for timely submission. If documentation is not received within that timeframe, the provider may receive up to three additional letters and/or phone contacts from CERT. Palmetto GBA may also place a courtesy call in response to the request. If CERT does not receive the records by the 75th day from the date of the initial letter, the CERT will notify Palmetto GBA to adjust the paid claim and recoup all payment for non-submission of documentation. Please see the CERT contractor’s letter and contact information on the CERT C3HUB portal.

CERT samples Medicare claims during a specific report year, each with a Universe Date, the date the claim entered the Medicare system. The claim with the oldest Universe Date will be reviewed first. For more information about the CERT report year, please visit cms.gov.

If CERT disagrees with the original payment of the claim, the MAC is notified and will adjust the claim based on CERT’s decision. Adjustments can be identified on the provider's remittance advice. Palmetto GBA will also send a Teaching and Instruction for Provider (TIP) education letter to the provider regarding the specific reason for the adjustment of the claim. A follow-up phone call may also be made by Palmetto GBA to ensure the provider understands why the claim was adjusted. Please complete the Contact Name and Phone Number section on the barcoded coversheet when submitting medical records to the CERT Contractor. This will assist Palmetto GBA in contacting the appropriate person in the event the claim is found in error for insufficient documentation. 

Please note:  If CERT agrees with Palmetto GBA’s original determination, the provider is not notified.

Providers can now access the CERT C3HUB to obtain claim review and documentation status under the claim status search feature. The C3HUB is operated by the CERT Contractor and updated daily. Providers may email JJ.JM.CERT@palmettogba.com for more information about the CERT review. Please do not contact the CERT Contractor for the review results of your claim. Refer to the Medicare Program Integrity Manual, Publication 100-08, Chapter 12 (PDF) for more information about how CERT information is disseminated.

Palmetto GBA also provides this information within eServices, our free, internet-based self-service portal. (Refer to the eServices User Guide for details.) CERT information can be found in eServices under the eReview tab and then by selecting the eAudit tab. This information is only updated monthly.

Yes. Follow the normal redetermination process to appeal all CERT denials. Providers are encouraged to use the optional CERT redetermination form which is available on the Palmetto GBA website (JJ Part A, JJ Part B, JM Part A, JM Part B, Railroad Medicare, Home Health and Hospice) and also through eServices. 

CERT and Palmetto GBA use the mailing address on file in the Medicare system. If your address is incorrect or has changed:

• Visit CMS website to obtain the CMS-855A form or the CMS-855B form to update your information. An original signature is required, so the form must be printed, signed and mailed and cannot be sent electronically.
• The Provider Contact Center can assist you with address changes.
  • Jurisdiction J (JJ): 877–567–7271
  • Jurisdiction M (JM): 855–696–0705
  • Railroad Medicare: 888–355–9165
• For information on updating addresses with PECOS, please see MLN Matters® Article SE1617 (PDF).

All initial letters requesting medical records will be sent to the address on file with PECOS. 

• After the initial request letter is sent on a specific CID, providers can designate a point of contact, address and/or phone number for future CERT correspondence related to that CID by calling a CERT Customer Service Representative (CSR) at 888–779–7477.
• Providers with at least five PTANs (Provider Transaction Numbers) or OSCAR (Transaction Access Number and NPI), such as a hospital chain with multiple PTANs, or billing practice with multiple NPIs, who would like to elect a single point of contact can enroll in the “chain address” program. Providers should contact CERT at the above number and/or email address. Please see the CERT contractor's letter and contact information on the CERT C3Hub for additional information and guidance concerning this.