decisionhealth Newsletters, Answer Books - 2006 Issue 10 (October)
Medicare_Program_Integrity_Manual / 3786
Subscribe or sign in to view the full article.
Article Overview
This article covers a Medicare Program Integrity Manual transmittal that updates Comprehensive Error Rate Testing (CERT) instructions for Medicare contractors and their interactions with the CERT contractor. It is relevant to contractors, program integrity staff, and compliance teams responsible for CERT-related documentation exchange, feedback, appeals, overpayment tracking, provider education, and error rate reduction planning. The article also includes revised review guidance and references to related Medicare coverage and coding materials used in CERT review.
Why This Topic Matters
The update affects how Medicare contractors coordinate with CERT, manage documentation and appeals, and support error rate reduction activities. It also signals where the manual’s operational guidance changed and where review instructions were added or clarified.
Article Sections
-
Summary of Changes
Overview of the transmittal’s purpose, effective and implementation dates, and the broad categories of manual revisions.
-
Changes in Manual Instructions
List of revised, new, and deleted chapter sections affected by the update.
-
Attachment: Business Requirements
Background, policy context, and implementation considerations supporting the manual revision.
-
Chapter 12 Table of Contents
Updated chapter navigation and the major CERT-related sections included in the manual.
-
12.3.1 Affiliated Contractor (AC)/Full PSC Communication With the CERT Contractor
Contact points, communication channels, web resources, and coordination methods used by contractors and the CERT contractor.
-
12.3.2 Overview of the CERT Process
General description of the CERT sampling, file exchange, and review workflow across Medicare contractors and the CERT operations center.
-
12.3.3.1 Providing Sample Information to the CERT Contractor
Operational guidance for submitting sampled claim information, related files, and associated administrative handling.
-
12.3.3.2 Providing Review Information to the CERT Contractor
Instructions for supplying supporting materials used in claim review and for coordinating related operational tasks.
-
12.3.3.3 Providing Feedback Information to the CERT Contractor
Feedback file handling, response timing, claim status reconciliation, and payment-related follow-up activities.
-
12.3.3.3.1 Disputing/Disagreeing With a CERT Decision
Processes for disputing or disagreeing with CERT determinations and the associated CMS review pathway.
-
12.3.4 Handling Overpayments and Underpayments Resulting From the CERT Findings
How contractors handle payment adjustments that follow CERT findings and the related beneficiary and provider considerations.
-
12.3.5 Handling Appeals Resulting From CERT Initiated Denials
Appeal processing expectations for CERT-initiated denials and coordination between contractors, providers, and CERT.
-
12.3.6.1 Tracking Overpayments
Tracking and reporting of completed collection activity and the related CERT status updates.
-
12.3.6.2 Tracking Appeals
Claim appeal status reporting, timing, and the effect of appeal outcomes on CERT records.
-
12.3.8 AC/Full PSC Requirements Involving CERT Information Dissemination
Expectations for sharing CERT-related information with providers and other contractors, including outreach and education support.
-
12.3.9 AC/Full PSC Error Rate Reduction Plan (ERRP)
Requirements for developing, submitting, and updating error rate reduction plans based on CERT findings.
-
12.3.10 Contacting Non-Responders
Guidance for identifying, contacting, and following up with providers who have not responded to CERT requests.
-
12.3.11 Late Documentation Received by the CERT Contractor
How late documentation is handled before and after error communication and how related claim status changes are addressed.
-
12.3.12 Voluntary Refunds
Treatment of voluntary refunds received in connection with claims selected for CERT review.
-
12.3.13 Local Coverage Determinations (LCD)/National Coverage Determination (NCD)
Coverage-related expectations tied to CERT review and the relationship to LCD and NCD guidance.
-
12.4 CERT Review Contractor Review Guidelines
High-level review guidance for the CERT contractor and the reference materials used in claim review.
-
A. E&M Services
Review guidance related to evaluation and management service documentation and coding review references.
-
B. 24 Hour Rule
Review guidance addressing date-of-service differences and how documentation is considered during CERT review.
What You Will Learn
- How the CERT process is organized within the Medicare Program Integrity Manual
- What contractor communication and documentation exchange requirements were updated
- How CERT-related feedback, overpayment, appeal, and late documentation workflows are structured
- What kinds of provider outreach and error rate reduction planning are included in the manual update
- What broad review guidance CMS directs the CERT contractor to use
Who Should Read This
- Medicare administrative contractors
- Program integrity staff
- Claims processing and medical review staff
- Compliance and audit personnel
- Healthcare reimbursement professionals
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com