Letter and Contact Information
The CERT Review Contractor issues an Additional Documentation Request (ADR) to obtain medical records for each claim line sampled for CERT review.
We strive to ensure that all contact with providers is as minimal and efficient as possible to accomplish the tasks with the least amount of effort or burden on the providers.
For Initial ADRs, the CERT Review Contractor follows this schedule:
Initial Request Schedule
- Day 0: Send letter 1 requesting documentation. The provider has 45 days from this letter to furnish the requested documentation.
- Day 25: Telephone contact to follow-up on request and/or offer assistance.
- Day 30: Send letter 2. The provider has 15 days left to complete the request.
- Day 40: Telephone contact to follow-up on request and/or offer assistance.
- Day 45: Send letter 3. (Response is due)
- Day 55: Telephone contact to follow-up on request and/or offer assistance. (Response is overdue)
- Day 60: Send letter 4. (Response is overdue)
- Day 76: Claim is counted as non-response error and is subject to overpayment recovery by the Medicare Administrative Contractor (MAC).
While conducting medical review of the documentation received, the medical review specialist may identify the need for additional information.
A new additional documentation request will be issued to obtain the specific item of missing documentation.
The response time for this second request is shorter. The CERT Review Contractor follows this schedule:
Subsequent Request Schedule
- Day 1: Send letter 1.
- Day 1: Telephone contact to follow-up on request and/or offer assistance.
- Day 10: Send letter 2.
- Day 10: Telephone contact to follow-up on request and/or offer assistance.
- Day 16: Claim back in review process.
Comprehensive Error Rate Testing (CERT) Program New Processes
All FIRST Additional Documentation Request (ADR) letters for CERT are sent to the address on file with the Provider Enrollment, Chain and Ownership System (PECOS) for the provider/supplier that billed/submitted the claim.
All SUBSEQUENT ADR letters can be sent to an alternate address. This can be provided to the CERT Customer Service Representative (CSR) by calling 888-779-7477.
The above processes are based on each individual CID; providers will need to contact the CERT office as mentioned above for each sampled claim.
For information on updating addresses with PECOS, please see MLN Matters® Article SE1617 for additional information.
Chain Address Program
Providers who have at least ten (10) PTAN/OSCAR numbers who would like to elect a single point of contact (POC) can participate in the “chain address” program recently implemented by CERT. This program is as follows:
Call the CERT office (888-779-7477) or your local MAC CERT Coordinator with a list of PTAN/OSCAR numbers and the designated point of contact information.
To assure you supply the information to CERT within the 45 days, CERT will email/call the point of contact with a list of outstanding CID numbers.
NOTE: Due to the FIRST letter being sent to the provider address on file, these may be requests the point of contact has not yet received.
When requested, the CERT CSR will forward a copy of the letters not yet received.
In order to reduce provider burden, when multiple calls are due to the same phone number, the CERT RC groups the calls so that a single contact can be made with the provider (providers) associated with that phone number to discuss all outstanding requests.
*****IMPORTANT NOTE: This change is ONLY in regards to the CERT program