Medicare Program Integrity Manual 
Chapter 12  The Comprehensive Error Rate Testing 
Program 
 
Table of Contents 
(Rev. 10709, 04-27-21) 
 
Transmittals for Chapter 12 
 
12.1  The Comprehensive Error Rate Testing (CERT) Program 
12.2  MAC Communication with the CERT Program 
12.3  Overview of the CERT Process 
12.4  CERT Process Requirements 
12.4.1  Providing Sample Information to the CERT Review Contractor 
12.4.2  Providing Review Information to the CERT Review Contractor 
  12.4.2.1 - MAC Responsibility After Workload Transition 
12.4.3  Providing Feedback Information to the CERT Review Contractor 
12.4.3.1  Disputing a CERT Decision 
12.5  Handling Overpayments and Underpayments MAC Feedback, and Appeals 
           Resulting From the CERT Findings           
12.6  Handling Appeals Resulting From CERT Initiated Denials 
12.6.1 - CERT Appeal Results 
12.7  Annual Certification of CERT Information   
12.8  Disseminating CERT Information 
12.9  Annual Improper Payment Reduction Strategy (IPRS) 
12.10 Additional Documentation Requests (ADRs) 
            12.10.1  Fraud Investigations 
           12.10.2  No Response to Additional Documentation Requests   
          12.10.3  Insufficient Response to Additional Documentation Requests 
12.11  Late Documentation Received by the CERT Review Contractor 
12.12  Voluntary Refunds 
12.13 Administrative Relief to Damaged Areas from a Disaster  12.1  The Comprehensive Error Rate Testing (CERT) Program 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
The Comprehensive Error Rate Testing (CERT) program produces a national Medicare 
Fee- for-Service (FFS) improper payment rate that is compliant with the Payment 
Integrity Information Act of 2019 (PIIA) and the implementing guidance in the Office of 
Management and Budget Circular A-123, Appendix C. 
 
The CERT program evaluates a stratified random sample of Medicare FFS claims to 
determine if they were paid or denied properly under Medicare coverage, coding, and 
billing rules. The CERT program considers any payment for a claim that should have 
been denied or that was made in the wrong amount (including both overpayments and 
underpayments) to be an improper payment. The claim can be counted as either a total or 
a partial improper payment, depending on the error. The findings can be projected to the 
entire universe of Medicare FFS claims because the CERT program ensures a statistically 
valid random sample. Therefore, the improper payment rate calculated from this sample 
is considered to be reflective of all claims processed by the Medicare FFS program 
during the report period. 
 
The  results  of  the  improper  payment  rate  calculation  are  published  annually  in  the 
Department of Health and Human Services Agency Financial Report, and the CMS 
Financial  Report.  More  information  about  the  CERT  program  is  available  at 
www.cms.hhs.gov/cert. 
 
12.2  MAC Communication with the CERT Program 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
A.  CERT Staff 
 
CMS CERT Team 
7500 Security Blvd 
Baltimore, MD 21244 Mail Stop C3-02-16 CERT@cms.hhs.gov 
 
B.  MAC CERT Points of Contact (POCs) 
 
Each MAC shall provide the CERT review contractor with the name, phone number, 
address, fax number, and email address of a general point of contact (POC) and an 
information technology (IT) POC. The MAC shall maintain, review and update the POC 
information via the administrative section of the C3HUB. The POC information shall be 
reviewed and updated by the MAC quarterly and when changes to the POC occur. The 
CERT review contractor will contact the IT POC to handle issues involving the exchange 
of electronic data. The CERT review contractor will contact the general POC to handle 
issues related to medical review decisions, payment adjustments, appeals, and other  CERT-related issues. Additionally, the CERT listserv is used to distribute 
announcements, meeting agendas, and additional CERT information. MACs may contact 
the CMS CERT team or CERT review contractor to add an individual to the CERT 
listserv. 
 
A.  CERT Information Sources for MACs 
 
  The CMS CERT website at https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Improper-Payment-Measurement-Programs/CERT 
  The CERT public website at https://c3hub.certrc.cms.gov/  
  The CERT C3HUB at https://c3hub.certrc.cms.gov/  
  The Data Dashboard at https://www.cert.cms.gov/LiveDashMerge/main.php 
  Quarterly forecast reports that are distributed via secure file transfer 
  End of year raw data reports that are distributed via secure file transfer 
 
12.3  Overview of the CERT Process 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
The CERT process begins when claims that have entered the claims processing system 
are extracted to create a claims universe file. This file is transmitted to the CMS Data 
Center (CMSDC) daily. A random sample from the claims universe file is selected for 
inclusion in the CERT sample. The sampled claims are held for a predefined period to 
allow the claim to be processed and paid by the MAC. After this waiting period, the 
sample information is sent to the MAC as a sampled claim transaction file. The MAC 
returns specific information about each claim to the CERT review contractor using the 
sampled claims resolution file, claims history replica file, and the provider address file 
formats. 
 
The CERT program uses the information obtained from the MAC to request 
documentation from the provider who submitted the sampled claim. The claim and the 
supporting documentation are reviewed by the CERT review contractor to determine if 
the claim was paid or denied appropriately based upon Medicare coverage, coding and 
billing rules. The CERT program collects additional information from the MACs for each 
claim considered to be in error via the feedback process. 
 
12.4  CERT Process Requirements 
(Rev. 852; Issued: 12-21-18; Effective: 1-24-19; Implementation: 1-24-19) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
12.4.1  Providing Sample Information to the CERT Review Contractor 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21)   
All data exchanged between the CMS Data Center (CMSDC) and the MAC virtual 
datacenters shall be in an electronic format via NDM CONNECT:DIRECT. 
 
The MAC virtual data centers shall submit a daily file containing information on claims 
entered during the day, in the formats specified in instructions available to a MAC CERT 
Point of Contact. MAC virtual data center responses to requests from the CERT program 
for claim information, shall follow the same instructions. 
 
A.  Claims Universe File 
 
The shared systems will create a mechanism for the MAC virtual data centers to be able 
to create the claims universe file, which will be transmitted daily to the CMSDC. The file 
will be processed through a sampling module residing on the server at CMSDC. The data 
centers shall ensure that the claims universe file contains all claims except home health 
agency request for anticipated payment claims that have entered the shared claims 
processing system. 
 
Canceled claims are included in the claims universe file because the decision to cancel 
the claim has not been made by the time the claims universe file is submitted. The data 
centers shall ensure that each claim included in the universe file is unique and may only 
be selected on the day it enters the system. 
 
B.  Sampled Claims Transaction File 
 
The shared systems shall create a mechanism for the data centers to receive a sampled 
claims transaction file from the CMSDC daily. This file will include claims that were 
sampled from the daily claims universe files. 
 
C.  Sampled Claims Resolution File and Claims History Replica File 
 
The shared systems shall create a mechanism for the data centers to match the sampled 
claims transaction file against the shared system claims history file to create a sampled 
claims resolution file and a claims history replica file. The claims history replica file is 
comprised of the claims history data file in the shared system format. These files shall be 
transmitted at the same time to the CMSDC. The resolution file is input to the CERT 
claim resolution process and the claims history replica file is added to the Claims History 
Replica database. 
 
The MAC data center shall furnish resolution information for all finalized claims 
included in the transaction file within five days of receipt of a request from the CERT 
review contractor. MACs receiving daily transaction files shall respond with resolution 
files (daily for Part A and DME, weekly for Part B). Resolution information on claims 
that have not finalized by the initial request shall be included at the first opportunity 
immediately after the claim has finalized. 
  The MAC data center shall provide the sampled claims resolution file(s) and the claims 
history replica file(s) for each iteration of the claim when the claim number changes 
within the shared system as a result of adjustments, replicates, or other actions taken by 
the MAC. The sampled claims transaction file will always contain the claim control 
number of the original claim. 
D.  Claims with Multiple Versions 
 
In many cases, after a provider submits a claim, a contractor or shared system or provider 
will submit an adjustment claim, split claim, or a replicate claim. An initial claim 
can have multiple adjustments or iterations made to it. When the sampled claim has been 
adjusted or otherwise has multiple versions linked to the sampled claim in the MAC 
claim processing system, the resolution file contains a separate record for each version of 
the claim. The CERT review contractor shall review the most current version of the claim 
that finalized before the date of the transaction file. The CERT review contractor shall 
not review any version of the claim that finalized after the date of the transaction file. The 
CERT review contractor shall use the claim adjudication date in the resolution record to 
determine when the claim finalized. 
 
E.  No Resolution Claims 
 
If a claim identified on the transaction file is not found on the shared system claims 
history file, no record should be created for that claim. These are called no-resolution 
claims. Each MAC shall take all necessary steps to minimize the number of no- 
resolution claims it submits to the CERT review contractor each year. The MAC may 
obtain a list of no-resolution claims for a given time period on either the Status Summary 
of Sample Claims page or the All Sampled Claims page of the C3HUB. If the MAC 
receives a request for a claim for which the shared system is not able to produce a 
resolution file, the MAC shall research the claim to determine why a resolution record 
was not produced. 
 
When the MAC identifies a no-resolution claim where the Health Insurance Claim 
Number (HICN) on the finalized claim is different from the HICN on the transaction 
request, the MAC shall notify the CERT review contractor of the correct HICN. The 
MAC shall not enter an acceptable no- resolution reason code for claims that finalized 
with a HICN different from the HICN on the transaction request. 
 
No-resolution claims with acceptable no-resolution reasons, which are entered by the 
CERT Point of Contact, will not be in the no-resolution rate. Should the MAC discover 
that one or more no-resolution claims has an acceptable reason, the MAC shall enter the 
appropriate acceptable 
no- resolution reason code on the C3HUB. 
 
The MAC shall keep documentation on file that supports the acceptable no-resolution 
reason. The MAC shall make this documentation available to CMS or the Office of 
Inspector General upon request. 
  F.  Provider Address File 
 
In addition to the claim resolution file, each MAC data center shall transmit the provider 
address file containing the names, known addresses, and telephone numbers of all the 
billing, attending, ordering/referring, and performing/rendering providers for all the 
claims on the resolution file. 
Each unique provider and address combination shall be included only once on each 
provider address file. 
 
12.4.2  Providing Review Information to the CERT Review Contractor 
(Rev. 852; Issued: 12-21-18; Effective: 1-24-19; Implementation: 1-24-19) 
 
The MAC shall indicate, in the resolution file, if the claim lines were subject to manual 
medical review or not. 
 
Upon request from CMS or the CERT review contractor, the MAC shall provide all 
applicable materials used by the MAC to make a payment decision on a CERT sampled 
claim. Normally, additional material is required on less than 10 percent of sampled 
claims. Each MAC shall provide the requested information to the CERT review 
contractor within 10 business days of the request. 
 
12.4.2.1  MAC Responsibility After Workload Transition 
(Rev. 852; Issued: 12-21-18; Effective: 1-24-19; Implementation: 1-24-19) 
 
When the workload transitions from one MAC to another, the MAC that assumes the 
workload shall follow-up on no documentation claims, MAC feedback, appeals, and all 
other efforts needed to produce an accurate improper payment rate. 
 
The assuming MAC shall not have access to the data until the individual workload has 
transitioned, unless otherwise negotiated with the outgoing MAC or approved by CMS. 
 
For CERT reporting purposes, any error will be assigned to the MAC that was 
responsible for the workload at the time the claim was processed. 
 
12.4.3  Providing Feedback Information to the CERT Review  
Contractor 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
A.  Requests for Feedback Information 
 
  Feedback is the mechanism by which the CERT review contractor notifies 
MACs of CERT review decisions. It also serves as the mechanism by which the MAC 
provides the CERT program with corrected pricing, which allows the program to 
determine the difference between what was allowed on the original claim and the amount 
that should have been allowed based on the CERT decision. On a daily basis, the CERT 
review contractor posts a description of errors it has found for each claim on the C3HUB.    
  The MAC shall correctly enter the Recalculated Allowed Amount in MAC 
feedback for all claims where the CERT review contractor disagreed with the MAC 
decision in adjudicating the claim. 
 
  The Recalculated Allowed Amount is not the paid amount. The recalculated 
allowed amount is the amount paid to the provider (or beneficiary) plus any deductible 
applied to this claim plus the copayment amount. 
 
When co-insurance or a deductible was applied to a claim/line resulting in no payment 
o 
to the provider, the MAC should enter the Recalculated Allowed Amount equal to the 
allowed amount before the deductible and/or co-insurance was applied. An entry of zero 
in the recalculated allowed amount results in payment error equal the deductible or co-
insurance applied. 
 
  Each MAC shall submit feedback information for all lines within 30 days of the 
date posted to the C3HUB, unless the MAC is actively working with the provider to 
obtain additional documentation for CERT review. Each MAC shall complete all the 
lines in the feedback process prior to the cut-off date for the report period.  If the feedback 
is not submitted by the end of the cut-off date for a report period, the lines will be 
counted as full payment errors. Deadlines for completing feedback are listed on the 
C3HUB under calendar of events which can be accessed from the main MAC Central 
page.  
 
  A MAC may contact the CERT review contractor MAC feedback coordinator, 
via the collaboration feature on the C3HUB, to request clarification about the results of a 
CERT review. 
 
B.  Repricing 
 
The MAC shall calculate the corrected allowed amount for each claim on the feedback 
report. The MAC shall take special care to report accurate information in the recalculated 
final allowed amount field. The recalculated final allowed amount is the amount that 
would be allowed for the line if the claim were paid at the level indicated after CERT 
review. It includes the paid amount, coinsurance, deductibles, and offsets. When 
appropriate, the MAC shall report recalculated final allowed amounts as the output from 
a payment calculator such as the PRICER prospective payment system (PPS). The 
PRICER PPS automatically adds the outlier payments into this output. Therefore, the 
outlier payment amount in value code 17 should not be added or subtracted from the 
recalculated final allowed amount. 
 
C.  Claims that are canceled/replaced on or after the date of the transaction file 
 
The CERT review contractor shall review the most current version of the claim that 
finalized before the date of the transaction file. Any cancelations, adjustments, or other 
actions that occur on or after the date of the transaction file are not applicable to the  CERT program reporting. 
 
If the claim is canceled/replaced on or after the transaction file date: 
  Feedback shall reflect the CERT decision. 
  Appeal information shall not be entered in the C3HUB. 
 
For the payment adjustment information in the C3HUB, the MAC may enter that the 
claim was canceled/replaced on or after the transaction file date and no payment or 
collection occurred. The MAC shall not use a CERT review decision from a claim that is 
canceled/replaced on or after the date of the transaction file on an adjustment claim. 
 
12.4.3.1  Disputing a CERT Decision 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
 
A dispute may be filed in situations in which the MAC does not agree with the final 
CERT review contractor decision on a claim. The MAC shall indicate the disputed claim 
on the C3HUB via the feedback process in accordance with this section.  Using the 
appropriate field in the C3HUB, the MAC shall enter a statement that explains the 
rationale for filing the dispute. Once a MAC files a dispute on a claim, they should not 
enter any feedback information on that claim since the claim will be removed from 
feedback. The CERT review contractor will conduct a re- review of the disputed claim 
and issue a new comment via the C3HUB. If the MAC does not agree with the re-review 
decision or new reviewer comment, the MAC has the option to escalate the dispute to 
CMS via the C3HUB feedback entry.  The MAC must provide a detailed rationale, via 
the appropriate field in the C3HUB, as to why the claim remains in dispute. The CMS 
dispute panel shall use the medical record, CERT review contractor comments, and MAC 
comments/rationales to review the disputed claim. The CERT review contractor shall 
notify the MAC of the CMS dispute panel final decision by way of the C3HUB. The 
CMS dispute panel decision will appear as a new reviewer comment, and the claim will 
appear in the new feedback posting. 
 
Each MAC is allowed to file two disputed claims per month on or before the last day of 
each month. Should the MAC choose not to submit a dispute in a given month, the 
unused opportunity does not carry over to the following month. 
 
When an appeal has been entered for a disputed claim, the MAC shall notify the CERT 
review contractor immediately via the C3HUB Appeal Data Entry page in order to halt 
the dispute process. 
 
12.5  Handling Overpayments and Underpayments Resulting from the 
CERT Findings 
(Rev.10709; 04-27-2021; Effective: 07-28-2021; Implementation: 07-28-2021)  
  This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
The instructions in this section apply only to overpayments and underpayments that result 
from CERT findings. The MAC shall continue to handle overpayments and 
underpayments resulting from non-CERT findings as instructed in other CMS manuals. 
 
The CERT review contractor notifies the MAC when an underpayment or an 
overpayment is identified via the C3HUB. The MAC shall adjust the claim to reflect the 
corrected code and payment amount and make the appropriate payment or collection. The 
MAC shall pay or collect the full amount in error as defined by the CERT- identified 
underpayment or overpayment. When the CERT reviewed claim was canceled on or after 
the transaction file date, the MAC shall not pay or collect the amount in error, as the 
claim has already been canceled (see 12.3.3.C). If shared systems logic limits the 
payment correction amount to a sum less than the full amount in error, the MAC shall 
pay the system allowed amount and educate the provider about future billing amounts. 
 
The MAC shall use the normal claim adjustment procedures published in Pub 100-04 
Claims Processing Manual. The MAC shall use the bill type XXH (CMS) to indicate 
the adjustment was due to a CERT review. 
 
For more information about the reason for the payment adjustment, contact the CERT 
MAC feedback coordinator. 
 
The MACs may temporarily suspend reason codes that prevent the adjustment of a 
CERT- initiated denial claim that will not process due to the age of the claim. The 
suspension shall only last long enough for the claim to be adjusted. Example: reason code 
36200 was not in effect when the initial claim processed. The CERT review contractor 
has now reviewed the claim and determined that it should be adjusted. The claim will not 
process because this edit cannot be overridden. 
 
The MAC shall provide the CERT program with the status and actual amounts of 
overpayment collections and underpayment payments. An overpayment is considered 
collected when the overpayment amount has been fully or partially collected, through 
provider overpayment check, offset or other payment arrangement. An overpayment is 
also considered collected if the MAC has failed to recoup the overpayment amount from 
the provider in a specified time and has referred the debt to treasury or another entity. 
The overpayment is not considered collected when the claim is adjusted or when only the 
accounts receivable is set-up. Similarly, an underpayment payment is reported only when 
the payment is made. The MAC shall make adjustments on zero-dollar errors to reflect a 
change in the reason for error. No actual collection or payment is made, and $0 shall be 
reported as the payment adjustment. 
 
A list of CERT identified overpayments and underpayments are provided to the MAC via 
the C3HUB. The list is updated each time the C3HUB is refreshed. The MAC shall report 
CERT identified overpayment and underpayment collection information using the CERT  payment adjustment section of the C3HUB. A multiple collection feature is available on 
the C3HUB for cases where the collection is received in installments. 
 
By the first business day in October, the MAC shall report the required payment 
adjustment information for all CERT identified overpayments and underpayments that 
have been collected or paid for the current report period unless otherwise directed. The 
MAC should access the payment adjustment section of the C3HUB to report collection or 
payment information throughout the year and enter information on an ongoing basis. 
 
12.6  Handling Appeals Resulting from CERT-Initiated Denials 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
The MAC shall process appeals stemming from a CERT-initiated denial. The MAC shall 
ensure that the appeal is handled appropriately as instructed in other CMS manuals. 
 
The MAC shall notify the CERT review contractor, using the C3HUB, when a CERT 
review decision is appealed. The MAC shall confirm that feedback has been completed 
before entering an appeal on the C3HUB. No further review shall be conducted by the 
CERT review contractor after the MAC has entered an appeal on the C3HUB. This 
includes instances in which additional documentation is received to support the claim. 
 
The MAC shall not enter an appeal in the C3HUB for a claim that was canceled on or 
after the transaction file date. When the MAC is not able to enter an appeal on the 
C3HUB because the claim was canceled on or after the transaction file date, the MAC 
may send documentation to the CERT review contractor for further consideration. 
 
Medical records for the appealed CERT claim may be obtained by contacting the CERT 
appeals coordinator via the appeals page on the C3HUB. The MAC shall enter all 
available information for MAC feedback and appeals for CERT sampled claims by the 
cut- off date listed on the C3HUB calendar. Appeal determinations entered into the 
C3HUB by the specified due date will be reflected in the report. 
 
12.6.1  CERT Appeal Results 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
It is essential that all CERT appeals be expedited, and that data be corrected and finalized 
in order to ensure its inclusion in the final national and contractor level calculations. 
 
  In order to finalize an appeal, the MAC shall enter the Date Appeal Process 
Finalized. The MAC shall enter the date for each level of appeal. 
    The Appeal Recalculated Allowed Amount is not the paid amount. The 
Appeal Recalculated Allowed Amount is the amount paid to the provider (or 
beneficiary) plus any deductible applied to this claim plus the co-insurance amount. 
  
  If co-insurance or a deductible was applied to a claim resulting in no payment to 
the provider, an entry of zero in the recalculated allowed amount results in payment error 
equal the deductible or co-insurance applied. 
 
For example, if $1,100 deductible is applied to a claim resulting in $0 claim paid amount, 
the allowed amount of $1,100 should be entered as the recalculated allowed amount. 
Payment errors are calculated by subtracting the recalculated amount from the final 
allowed amount.  If the claim paid amount of $0 was entered as the recalculated amount a 
payment error of $1,100 would be calculated. 
 
  The contractor shall access the C3HUB and correct any incorrect entries. 
 
12.7 Annual Certification of CERT Information 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
Annually, by October 15th, MACs shall submit a certification that all required 
information (e.g., overpayments and underpayments identified by CERT, MAC feedback, 
appeals, and recoveries) has been completely and accurately entered on the C3HUB. The 
MACs Certifying Official (for example, President, Senior VP, or Contract Project 
Manager) shall sign the certification and submit it to CMS as instructed in the MAC 
statement of work deliverable schedule. 
 
Certification statements shall include the following: 
  MAC Name 
  Contractor/Jurisdiction Number 
  Date certification submitted to CMS: [MM/DD/CCYY] 
  Fiscal Year [include the appropriate year] 
  Name of MAC Certifying Official 
  Title of MAC Certifying Official 
  A statement certifying the completeness and accuracy of the information entered 
in the C3HUB 
 
12.8  Disseminating CERT Information 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
Each MAC shall disseminate information concerning the CERT program to the provider  community. Each MAC shall educate the provider community about the CERT program 
and the importance of responding to CERT requests for medical documentation. A MAC 
shall disclose the review status and the result of a review to the provider upon request. 
The MAC shall obtain the review information from the C3HUB. 
 
12.9  Annual Improper Payment Reduction Strategy (IPRS) 
(Rev. 852; Issued: 12-21-18; Effective: 1-24-19; Implementation: 1-24-19) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
The annual IPRS is a problem-focused, outcome-based operational plan developed by the 
MAC that identifies risks to the Medicare Trust Fund and describes the improper 
payment interventions to be implemented to ensure proper payments and address the 
risks. The IPRS addresses both provider- and service-specific vulnerabilities and includes 
a prioritization of the problems based on data analysis findings and the availability of 
resources. 
 
The MAC shall submit an IPRS as directed by the Statement of Work and Contracting 
Officers Representative (COR). The current IPRS shall be updated or revised as required 
by the COR after review by the Medical Review (MR), CERT, and Provider Outreach 
and Education Business Function Leads and the Regional Office Technical Monitor MR 
staff. 
 
See Pub 100-08 Medicare Program Integrity Manual, Chapter 7, section 7.1 for specific 
instructions on the IPRS. 
 
12.10 Additional Documentation Requests (ADRs) 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
A.  General 
 
The CERT review contractor sends the additional documentation request (ADR) to the 
billing provider/supplier. If the CERT review contractor determines that documentation is 
missing or insufficient to make a determination on a claim, a subsequent ADR may be 
sent to the billing provider/supplier, the ordering/referring provider, or a third-party, as 
appropriate. 
 
B.  Additional Documentation Request Letters 
 
When requesting medical records from providers, suppliers, and third-parties, the CERT 
review contractor uses CMS approved ADR letters, found at 
https://c3hub.certrc.cms.gov/ The CERT review contractor sends ADRs in Spanish to  providers in Puerto Rico and upon request to providers in other regions. 
 
12.10.1  Fraud Investigations 
(Rev. 852; Issued: 12-21-18; Effective: 1-24-19; Implementation: 1-24-19) 
 
A MAC may contact the CERT review contractors medical records manager to request a 
cease in provider or supplier contact because the provider or supplier is part of an 
ongoing investigation.  In such cases, the MAC is responsible for providing written 
confirmation of the request to cease making provider or supplier contact. These requests 
require CMS approval.    
 
12.10.2  No Response to Additional Documentation Requests  
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
If documentation is not received within 75 days of the first ADR, the claim is a no 
documentation error with error code 99. Error code 99 claims are posted to the C3HUB 
on the 76th day from the date the first ADR was sent and will appear in the next MAC 
feedback posting. 
 
For claims with error code 99, the MACs may proceed at their discretion by doing one of 
the following: 
 
i.  Contact those providers who have failed to submit medical records and encourage 
them to submit the requested records to the CERT review contractor for review. The 
MACs should not complete  feedback while they are working with the provider to obtain 
documentation and/or the CERT review contractor is reviewing the claim; 
 
ii.  Complete MAC feedback in accordance with section 12.3.3 of this chapter and 
collect the overpayment immediately in accordance with section 12.4 of this chapter; or 
 
iii.  Collect the overpayment within 10 business days of the deadline for entering final 
MAC feedback. 
 
The MAC shall not contact any provider or supplier selected for CERT review until 30 
days after the first CERT ADR has been reported on the C3HUB. The MAC may contact 
the third-party and encourage them to send the needed medical record documentation to 
the CERT review contractor. When contacting providers or suppliers, the MAC shall 
remind them to include the barcoded cover sheet included with the CERT request or the 
CERT claim identification number at the top of the medical record. The MAC can 
download a barcoded cover sheet from the C3HUB if needed. 
 
12.10.3  Insufficient Response to Additional Documentation Requests 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
If the documentation submitted is inadequate to support payment for the 
service/item billed, or if the CERT review contractor could not conclude that the  billed service/item was actually provided, was provided at the level billed, and/or 
was medically necessary, the claim is an insufficient documentation error with 
error code 21. 
 
Error code 21 claims will be posted under the MAC feedback section of the C3HUB. 
MACs  should  reach  out  to  the  provider  or  supplier  to  submit  the  requested 
documentation to the CERT review contractor. 
 
12.11  Late Documentation Received by the CERT Review Contractor 
(Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
The MACs may submit any additional documentation received from the provider or 
supplier to the CERT review contractor for consideration as late documentation. 
 
If the CERT review contractor receives late documentation before the review decision is 
posted on the C3HUB, the CERT review contractor reviews the late documentation and 
scores the claim appropriately. If the CERT review contractor receives late 
documentation after the review decision has been posted on the C3HUB, the CERT 
review contractor checks to see if the MAC has entered an appeal in the C3HUB. If the 
MAC has entered an appeal for the CERT-initiated denial in the C3HUB, the CERT 
review contractor does not review the late documentation. If the MAC has not entered an 
appeal for the CERT-initiated denial in the C3HUB, the CERT review contractor reviews 
the late documentation and scores the claim appropriately. If the late documentation is 
received in time to complete review before the cutoff date to receive late documentation 
for the report, it is included in that years improper payment rate calculation. 
 
The MAC shall notify the provider of the change in denial reason. These cases are 
included in the feedback section of the C3HUB. 
 
12.12  Voluntary Refunds 
(Rev. 852; Issued: 12-21-18; Effective: 1-24-19; Implementation: 1-24-19) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
If the MAC receives a voluntary refund from a provider or supplier on a CERT sampled 
claim, the MAC shall process the voluntary refund normally, as instructed in other 
manuals. If the MAC processes the voluntary refund of a CERT sampled claim after 
receiving the transaction file for the claim in question, the MAC shall complete the 
feedback file as though the voluntary refund had not been received. 
 
12.13  Administrative Relief to Damaged Areas from a Disaster   (Rev. 10567; Issued: 01-20-21; Effective: 01-18-21; Implementation: 01-29-21) 
 
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive 
Error Rate Testing (CERT) as indicated. 
 
A.  General 
 
In the event of a disaster, the CERT program shall grant temporary administrative relief to 
any affected providers and suppliers. The administrative relief available to the CERT 
program is discussed below. 
 
B.  Definition of a Disaster 
 
A disaster is defined as any natural or man-made catastrophe (e.g., hurricane, tornado, 
earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing, 
fire, flood, explosion, etc.) which causes damage of sufficient severity and magnitude to 
partially or completely destroy medical records and associated documentation that could 
be requested by the CERT review contractor in the course of medical review, interrupt 
normal mail service (including US Postal delivery, overnight parcel delivery services, 
etc.), and/or otherwise significantly limit the provider or suppliers daily operations. A 
disaster may be widespread and impact multiple structures (e.g., a regional flood) or 
isolated and impact a single site only (e.g., water main failure). 
 
A provider or supplier must submit a disaster attestation (available on the CERT public 
website and upon request) when the documentation requested to support a claim has been 
wholly or partially destroyed in a disaster. The CERT review contractor shall accept an 
attestation that no medical records exist due to a disaster. 
 
C.  Administrative Relief 
 
Once a disaster has been declared, CMS will notify the CERT review contractor to grant 
temporary administrative relief to those providers or suppliers in areas that have been 
declared a disaster by the Secretary of the Department of Health and Human Services. 
Please refer to the CMS Emergency Response and Recovery website at 
https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home 
for information on current and past emergencies. 
 
The CERT review contractor shall apply administrative relief along with flexibilities and 
waivers related to medical review at the direction of CMS. The administrative relief is to 
be granted to affected providers and suppliers in accordance with the following 
guidelines: 
 
  The CERT review contractor shall not send any additional documentation 
requests (ADRs), attempt telephone calls to request medical documentation, or finalize 
review decisions on claims, as directed by CMS, to providers and suppliers affected by 
the disaster as determined by locations listed on the CMS Emergency Response and  Recovery website or as determined by CMS. This administrative relief starts on the date 
the disaster is effective. 
 
  Administrative relief does not include claims that have completed CERT review 
or assigned an error code 99 as a no documentation error before the administrative relief 
began. 
 
  Administrative relief is applied to entities when the physical location or mailing 
address of the provider or supplier is in the area impacted by the disaster. 
 
The MACs may obtain a list of claims impacted by administrative relief in the Claims 
Status Section on the C3HUB. 
  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R10709PI 04/27/2021  Update to Chapter 12 (The Comprehensive  07/28/2021 11488 
Error Rate Testing (CERT) Program) of 
Publication (Pub.) 100-08 
R10567PI 01/20/2021  Update to Chapter 12 (The Comprehensive  01/29/2021 12112 
Error Rate Testing (CERT) Program) of 
Publication (Pub.) 100-08 
R905PI  09/27/2019  Update to Chapter 12 (The Comprehensive  12/30/2019 11329 
Error Rate Testing (CERT) Program) of 
Publication (Pub.) 100-08 
 
R883PI  05/31/2019  Update to Chapter 12 (The Comprehensive  08/30/2019 11283 
Error Rate Testing (CERT) Program) of 
Publication (Pub) 100-08 (Medicare Program 
Integrity Manual) 
R852PI  12/21/2018  Update to Chapter 12 (The Comprehensive  01/24/2019 10931 
Error Rate Testing (CERT) Program) of 
Publication (Pub.) 100-08 (Medicare 
Program Integrity Manual) 
R800PI  06/15/2018  Comprehensive Error Rate Testing (CERT)  07/17/2018 10778 
Update to Chapter 12 of Publication (Pub.) 
100-08 
R774PI  03/02/2018  Comprehensive Error Rate Testing (CERT)  03/19/2018 10485 
Program Dispute Process 
R766PI  02/02/2018  Comprehensive Error Rate Testing (CERT)  03/02/2018 10442 
Updates to Chapter 12 of Pub. 100-08 
R743PI  09/08/2017  Comprehensive Error Rate Testing (CERT)  10/10/2017 10242 
Program Dispute Process 
R691PI  12/16/2016  Contacting Non-Responders and  01/19/2016 9856 
Documentation Requests 
R686PI  11/10/2016  Comprehensive Error Rate Testing (CERT)  12/12/2016 9846 
Program: Medicare Administrative 
Contractor (MAC) Certifying Official 
R622PI  10/30/2015  Program Integrity Manual Chapter 12  12/07/2015 9391 
Revision 
R595PI  05/22/2015  Comprehensive Error Rate Testing (CERT)  06/23/2015 9156 
Program Treatment of Power Mobility 
Device (PMD) and Repetitive Scheduled 
Non-Emergent Ambulance Transport Claims 
in the Prior Authorization Model  Rev #  Issue Date  Subject  Impl Date  CR# 
R560PI  12/12/2014  Program Integrity Manual Chapter 12  01/01/2015 8905 
Revisions 
R504PI  02/05/2014  Revision to Chapter 12 of the Medicare  03/06/2014 8591 
Program Integrity Manual - The 
Comprehensive Error Rate Testing Program 
R240PI  02/08/2008  Review the Fiscal Intermediary Shared  04/07/2008 5915 
System (FISS) to Include All 11x Claims in 
the Nightly Universe Files Generated for the 
Comprehensive Error Rate Testing (CERT) 
Program 
R204PI  05/25/2007  Comprehensive Error Rate Testing (CERT)  06/25/2007 4120 
Program Changes 
R115PI  07/22/2005  PIM Revision  CERT Support Actions  08/22/2005 3786 
R077PI  05/28/2004  Comprehensive Error Rate Testing (CERT)  06/28/2004 3229 
Requirements 
R071PI  04/09/2004  Rewrite of Program Integrity Manual (except  05/10/2004 3030 
Chapter 10) to Apply to PSCs 
R067PI  02/27/2004  Comprehensive Error Rate Testing (CERT)  03/12/2004 2976 
Requirements 
R012PIM 09/20/2002  Clarification & Manualization of Chapter  N/A  1143 
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