CERT Additional Documentation Request Letter Schedule Changes
The Comprehensive Error Rate Testing (CERT) review contractor issues an Additional Documentation Request (ADR) to obtain medical records for each claim line sampled for CERT review. The CERT review contractor initial letter request schedule has changed. Beginning with Review Year (RY) 2026 providers will only have 60 days to respond to these requests and if no records have been submitted, your claim will deny for non-response. Responding within 45 days, if not before, is always best practice to ensure timeliness.
CERT Review Contractor Schedule for Initial ADRs
Initial Request Schedule
For claims with universe date prior to July 1, 2024 (Report Year 2025 and earlier):
- Day 0: Send letter 1 requesting documentation. The provider has 45 days from this letter to furnish the requested documentation.
- Day 21: 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 35: Telephone contact to follow-up on request and/or offer assistance.
- Day 45: Send letter 3. Response is due.
- Day 49: 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).
For claims with universe date on or after July 1, 2024 (Report Year 2026 and later):
- Day 0: Send letter 1 requesting documentation. The provider has 45 days from this letter to furnish the requested documentation.
- Day 21: 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 35: Telephone contact to follow-up on request and/or offer assistance.
- Day 45: Send letter 3. Response is due.
- Day 49: Telephone contact to follow-up on request and/or offer assistance. Response is overdue.
- Day 61: Claim is counted as non-response error and is subject to overpayment recovery by the Medicare Administrative Contractor (MAC).
Subsequent Request Schedule
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:
- 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.
Claim Universe Dates — Each reporting year contains claims submitted July 1 two years before the report through June 30 one year before the report. For example, reporting year 2024 contains claims submitted July 1, 2022 through June 30, 2023.