TrailBlazer Health Enterprises

Education Makes the Difference

Comprehensive Error Rate Testing (CERT) Program

CMS uses the CERT program to measure and improve the payment accuracy of Medicare claims. Each year CMS receives over 2 billion claims, and CERT selects a random sample of these claims to review for accuracy. The results of these reviews produce local, regional and national error rates. CMS uses this information to educate and prevent errors in the future. How CERT Works CERT calculates a national paid claims error rate, a contractor-specific error rate and error rates for certain services. These error rates show how well each contractor, like TrailBlazer, processed claims. Claim or line errors also mean that providers will have services denied and money recouped. The CERT Process 1. CERT selects a random sample of claims submitted in a specific calendar year. 2. Then CERT requests medical records from providers for claims in the sample. 3. Next the claims and medical records are reviewed to see if they comply with the Medicare coverage, coding and billing rules. 4. If errors are found, money is recouped from providers. This can happen when: o Providers dont submit any documentation. o Providers submit insufficient documentation. o The medical record submitted indicates that the service was not medically necessary, was incorrectly coded, or was not in compliance with some other Medicare rule. The CERT Request The request is mailed in this envelope, includes the official CMS logo and contains: Claim cover sheet. List of the medical documentation requested. Claims attachment pull list. Instructions on how to mail, fax or send records using Electronic Submission of Medical Documentation (esMD).

What Do I Need to Do?

Published October 2011 JA

2011 TrailBlazer Health Enterprises/TrailBlazer. All rights reserved.

Provide Requested Information. If you are selected for review by CERT, you will be asked to provide complete medical records to support the medical necessity of each claim. Forwarding these records to CERT does not violate the Health Insurance Portability and Accountability Act (HIPAA). You do not need to get consent from the patient because in the conditions of participation you agreed to provide Medicare with anything needed to process claims. Also, CERT isnt authorized to pay for the cost of duplicating or mailing these records. If you use a photocopy service, please make sure they dont invoice CERT. Check Your Signatures. In Change Request (CR) 6698, CMS updated its signature requirements for claims that are medically reviewed by any Medicare contractor, including CERT. Illegible signatures are a common problem that can be solved by using either a signature log or attestation statement. Examples can be found on the CERT Provider Web page below. For more information, please see these links: o http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf. o http://www.trailblazerhealth.com/Publications/Job Aid/DocumentationSignatureRequirements.pdf. o https://www.certprovider.com/certproviderportal/pages/Signature_Attestation_State ment.pdf. Respond Promptly. If you receive a letter from CERT requesting medical documentation, pay special attention to the records deadline. CERT will send you an Additional Documentation Request (ADR) and four letters within a 60-day period. If you dont send the records within 75 days from the date of the first request letter, the claim will automatically be denied and money recouped. Keep Your Contact Information Current. It is vitally important for providers to keep enrollment information current. Providers are required to report any changes to mailing addresses, phone numbers, practice locations, etc., to the Medicare Administrative Contractor (MAC) within 90 days of the change. Providers must also notify the CERT contractor separately of any changes so CERT requests are handled in a timely manner. To change your address or contact information with CERT, please use the provider address directory on the CERT Web site: https://www.certprovider.com/.

How to Submit Medical Record Documentation You may send the records to CERT by mail, fax or esMD. The records are due as soon as possible after you receive the initial request. If the information is not received within 75 days of the first request, CERT must assume the services were not rendered and deny them. This is then counted as an error against both you and your MAC, TrailBlazer.

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Be sure your medical records department places a high priority on CERT requests. If you are mailing the requested documentation, please: 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 being submitted for review. For additional information, including a sample signature attestation form, please visit the CERT Web site at https://www.certprovider.com/ or call (301) 957-2380 or (888) 779-7477.

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