decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Program_Memos / 2000 / AB-00-29
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Article Overview
This article covers a Medicare program memorandum from HCFA/DHHS that introduces the CERT program and describes operational and standard system requirements for Medicare contractors. It focuses on the flow of claims-related files, contractor responsibilities, implementation timing, and the file-format guidance needed to support CERT reporting and review processes. The content is relevant to Medicare operations, systems support, and claims processing staff working with Part B and DMERC environments.
Why This Topic Matters
It matters because it defines Medicare contractor workflow and data exchange expectations tied to a national error-rate testing initiative, including implementation timelines and standard system updates. Organizations responsible for claims processing, reporting, and systems integration need this guidance to understand what the memorandum requires at a high level.
Article Sections
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Purpose
Introduces the memorandum’s scope and the two main areas addressed: CERT program requirements and standard system changes to support claims data exchange.
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Background
Provides context for the CERT initiative, its intended oversight function, and the types of claims-review outcomes the program is designed to support.
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Overview of the CERT Process
Summarizes the general flow of claims data between contractor systems and the CERT operations center, including sampling, tracking, review, and follow-up.
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Impact on Carriers, Intermediaries, DMERCs, and Regional Home Health Intermediaries (RHHIs)
Outlines contractor responsibilities for supporting the CERT project, including information exchange, follow-up activities, and coordination with the CERT contractor.
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Impact on Carrier and DMERC Standard System
Describes the standard system file exchange requirements for carrier and DMERC environments and notes that intermediary requirements will be addressed later.
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Claims Universe file
Presents the general structure and data elements for the daily claims universe submission used in the CERT process.
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Sampled Claims Transaction file, Sampled Claims Resolution file and Claims History Replica file
Describes the sampled claims data returned to contractors and the related resolution and history files used to complete the CERT workflow.
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Provider Address file
Outlines the file used to transmit provider mailing information associated with sampled claims.
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Assumptions and Constraints
Lists implementation and transmission assumptions, including handling of empty files, rejected files, and supporting data dictionary expectations.
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CERT Formats for Carrier and DMERC Standard Systems
Contains attachment material with detailed file-layout specifications for the CERT-related carrier and DMERC standard system files.
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Claims History Replica file
States that this file mirrors the individual standard system claims history format and excludes header and trailer records.
What You Will Learn
- The general purpose of the CERT program within Medicare contractor oversight.
- Which contractor groups are affected by the memorandum.
- How CERT-related claims data moves between contractor systems and the CERT operations center.
- What kinds of file formats and record layouts are included in the attachment.
- The implementation timing and operational scope described by the memorandum.
Who Should Read This
- Medicare contractors
- Claims processing personnel
- Medical coding and billing operations staff
- Revenue cycle and reimbursement systems staff
- Health IT and standard system support teams
- Compliance and program integrity staff
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