Q. What does the acronym C.E.R.T. stand for?
A. CERT stands for Comprehensive Error Rate Testing.
Q. Who is responsible for administering the CERT Program?
A. AdvanceMed is the PSC responsible for administering the CERT Program.
Q. Who is responsible for communicating with the CERT contractor for the Region A DMERC?
A. TriCenturion, the PSC for DMERC Region A, is responsible for reporting all CERT related activities within Region A to AdvanceMed.
Q. How are providers alerted that one or more of their claims has been selected for review in the CERT Program?
A. AdvanceMed will send an initial request letter to each provider followed by a series of letters and phone calls to the provider if they do not receive the requested documentation within 25 days of the initial letter.
Q. What documentation should providers send to AdvanceMed?
A. Providers should send all records, including medical records that support the payment of the item(s) billed on the claim.
Q. Where should providers send the documentation that is requested by AdvanceMed?
A. Providers can mail the documentation to:
AdvanceMed
1530 East Parham Road
Richmond, VA 23228
The best way to submit the documentation for CERT claims is to fax it to AdvanceMed at the following fax numbers: (804) 864-9980 and (804) 264-3268.
Q. How does AdvanceMed log and track the claims they review?
A. Every claim sampled in the CERT Program is assigned a Claim Identification Number referred to as a CID.
Q. What is the significance of the barcode sheet?
A. The barcode sheet is just another way of identifying a claim selected in the CERT program. The barcode sheet that providers receive with the CERT documentation request should be returned to AdvanceMed when a provider submits their documentation to AdvanceMed.
Q. What if a claim is determined by CERT to have been paid incorrectly?
A. Overpayments will be recouped for those claims that the CERT program determined to have been paid incorrectly. Providers will follow normal procedures for submitting appeals.
Q. What do providers risk in not responding to the request made by AdvanceMed?
A. Providers that do not respond to the CERT request will receive an “error” and will be assessed an overpayment. Providers who repeatedly do not respond to a CERT request for documentation are considered “recalcitrant”. Recalcitrant providers with a claim line total or claim total of $40.00 or more in question will be referred to the OIG for action.