Your CERT Claim Has Denied. Now What?
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.
Where Can I Find My Results?
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. You may also email JJ.JM.CERT@palmettogba.com for more information about your 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.
What Should I do if I Have the Documentation or Disagree?
Please review CERT’s review decision(s) to see specifically what medical records were supplied to the CERT Contractor and what documentation may have been missing. If you don’t agree with CERT’s review decision. You have one of two options:
- Send the records to CERT as late documentation
- Submit any additional or missing documentation
- Monitor your claim status on the C3Hub to assure CERT has completed the review within 120 days
- Follow the normal redetermination process to appeal if your claim has been adjusted due to CERT’s review decision
- Submit the appeal request within 120 days from the date of the remittance advice
- Submit additional or missing documentation with the appeal request, if applicable
- Use the Redetermination form located on our eServices portal or on our website at:
- Jurisdiction J Part A (PDF)
- Jurisdiction J Part B (PDF)
- Jurisdiction M Part A (PDF)
- Jurisdiction M Part B (PDF)