100-08 Medicare Program Integrity Manual: Chapter 12 - The Comprehensive Error Rate Testing Program

Medicare Program Integrity Manual
Chapter 12 – The Comprehensive Error Rate Testing
Program
Table of Contents
(Rev. 13890; Issued: 07-30-26)
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 – No Response to ADR
12.10.2 – Insufficient Response to ADRs
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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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 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
https://www.cms.gov/data-research/monitoring-programs/improper-payment-
measurement-programs/comprehensive-error-rate-testing-cert.
12.2 – MAC Communication with the CERT Program
(Rev. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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
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 quarterly by the MAC 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.
C. CERT Information Sources for MACs
• 	The CMS CERT website at https://www.cms.gov/data-research/monitoring-
programs/improper-payment-measurement-programs/comprehensive-error-rate-
testing-cert
• 	The CERT C3HUB at https://c3hub.certrc.cms.gov/
• 	The Data Dashboard at
https://www.cert.cms.gov/LiveDashMerge/main.php
• 	Quarterly pre-appeal rate documents that are distributed via secure file
transfer
• 	Final MAC-specific 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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
This section applies to Medicare Administrative Contractors (MACs) and Comprehensive
Error Rate Testing (CERT) as indicated.
The CERT sampling process begins with the CERT statistical contractor sampling from
shared systems claims in the Integrated Data Repository (IDR). The CERT statistical
contractor will ensure that the sampling universe only contains one record of each unique
claim. The CERT statistical contractor transmits files containing the sampled claims to
the CERT review contractor twice monthly.
The CERT review contractor 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. Claims sampled from the IDR are matched and
reconciled with this CMSDC universe. 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. 13890; Issued: 07-30-26; Effective: 08-28-26; Implementation: 08-28-26)
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. 	Sampling Universe File
The sampling universe file is the universe of claims from which the sample is selected.
The CERT statistical contractor creates the sampling universe file using the IDR, which
contains an extract of all valid claims that have entered the claims processing system.
Each claim in the sampling universe file is reported only once.
Claim adjustment records are excluded from the sampling universe file to ensure that
only one record per claim is available for sampling. This prevents the CERT statistical
contractor from selecting the same claim more than once in the sample.
B. 	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
data centers shall ensure that the claims universe file contains all 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 ensure that each claim included in the universe file is unique.
C. 	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 by the CERT program.

D. 	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 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 because 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.
E. 	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. If the adjusted/replacement claim is not included in
the resolution file, the CERT review contractor reviews the original claim as contained in
the resolution file and makes a determination based on the original claim regardless of
the claim being cancelled and/or adjusted.
F. 	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 included 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.
G. 	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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)

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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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. Daily, 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.
o 	When co-insurance or a deductible was applied to a claim/line resulting in
no payment 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 to the deductible or co-
insurance applied.
• 	Each MAC shall submit feedback information for all lines within 30 days of the
date posted to 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 the 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.13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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 detailed 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 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 Medicare coverage, coding, and billing rules in effect for the
billed date of service, 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 two disputes in a given month, the
unused opportunity does not carry over.
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 to halt the
dispute process.
12.5 – Handling Overpayments and Underpayments Resulting from the
CERT Findings
(Rev. 13890; Issued: 07-30-26; Effective: 08-28-26; Implementation: 08-28-26)
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 12.4.3.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 adjust 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.
In accordance with the CERT Review Schedule (available on the C3HUB), 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 deadline for completing payment adjustment
information is listed on the C3HUB under calendar of events which can be accessed from
the main MAC central page. In general, 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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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.
For instances where an appeal is dismissed or canceled, the claim is placed back into the
normal CERT review process.
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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
All CERT appeals must be expedited, and data must be corrected and finalized to ensure
its inclusion in the final national and contractor level calculations.
• 	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 to the deductible or co-insurance applied.
For example, if a $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. 12642; Issued: 05-16-24; Effective: 06-17-24; Implementation: 06-17-24)

This section applies to Medicare Administrative Contractors (MACs) and Comprehensive
Error Rate Testing (CERT) as indicated.
Annually, by September 30th, 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
MAC’s 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. 12959; Issued: 11-14-24; Effective:12-17-24; Implementation: 12-17-24)
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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)

This section applies to Medicare Administrative Contractors (MACs) and Comprehensive
Error Rate Testing (CERT) as indicated.
A. General
The CERT review contractor sends the 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. ADR Letters
When requesting medical records from providers, suppliers, and third parties, the CERT
review contractor uses CMS approved ADR letters. The CERT review contractor sends
ADRs in Spanish to providers in Puerto Rico and upon request to providers in other
regions.
12.10.1 – No Response to ADR
(Rev. 13890; Issued: 07-30-26; Effective: 08-28-26; Implementation: 08-28-26)
If documentation is not received within 60 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 61st 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 12.4.3 of this chapter and
collect the overpayment immediately in accordance with section 12.5 of this
chapter; or
Regardless of the option selected above, the MAC must complete feedback at least 30 days
prior to the deadline to submit late documentation posted on the C3HUB.
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 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
cover sheet from the C3HUB if needed.
12.10.2 – Insufficient Response to ADRs
(Rev. 13890; Issued: 07-30-26; Effective: 08-28-26; Implementation: 08-28-26)
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 provided, was provided at the level billed, and/or was medically necessary, the claim
is an insufficient documentation error with error code 21 assigned.
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.
12.10.3 – Insufficient Response to ADRs
(Rev. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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 provided, was provided at the level billed, and/or was medically necessary, the claim
is an insufficient documentation error with error code 21 assigned.
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. 13678; Issued: 03-12-26; Effective: 04-13-26; Implementation: 04-13-26)
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 before the cutoff date to receive late documentation for the report (in time to

complete review before the cutoff dates for the report) it is included in that year’s
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. 12959; Issued: 11-14-24; Effective:12-17-24; Implementation: 12-17-24)
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 supplier’s 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 https://c3hub.certrc.cms.gov/ 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/what-we-do/emergency-response 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) or attempt telephone calls to request medical documentation 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
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.
• 	If at any time documentation is received from the provider or supplier for claims
impacted by administrative relief, the CERT review contractor will proceed with
review.
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#
R13890PI 07/30/2026 	Revisions to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) and
Exhibit 46 in the Exhibits Chapter of
Publication (Pub.) 100-08 (Medicare
Program Integrity Manual)
08/28/2026 14539
R13678PI 03/12/2026 	Revisions to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08 (Medicare
Program Integrity Manual)
04/13/2026 14399
R12959PI 11/22/2024 	Revisions to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08 (Medicare
Program Integrity Manual)
11/22/2024 13842
R12642PI 05/16/2024 	Revisions to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08 (Medicare
Program Integrity Manual) and Deletions to
Exhibit 34 in the Exhibits Chapter of Pub.
100-08
06/17/2024 13602
R10709PI 04/27/2021 	Update to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08
07/28/2021 11488
R10567PI 01/20/2021 	Update to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08
01/29/2021 12112
R905PI 	09/27/2019 	Update to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08
12/30/2019 11329
R883PI 	05/31/2019 	Update to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub) 100-08 (Medicare Program
Integrity Manual)
08/30/2019 11283
R852PI 	12/21/2018 	Update to Chapter 12 (The Comprehensive
Error Rate Testing (CERT) Program) of
Publication (Pub.) 100-08 (Medicare
Program Integrity Manual)
01/24/2019 10931
R800PI 	06/15/2018 	Comprehensive Error Rate Testing (CERT)
Update to Chapter 12 of Publication (Pub.)
100-08
07/17/2018 10778

Rev # 	Issue Date 	Subject 	Impl Date CR#
R774PI 	03/02/2018 	Comprehensive Error Rate Testing (CERT)
Program Dispute Process
03/19/2018 10485
R766PI 	02/02/2018 	Comprehensive Error Rate Testing (CERT)
Updates to Chapter 12 of Pub. 100-08
03/02/2018 10442
R743PI 	09/08/2017 	Comprehensive Error Rate Testing (CERT)
Program Dispute Process
10/10/2017 10242
R691PI 	12/16/2016 	Contacting Non-Responders and
Documentation Requests
01/19/2016 9856
R686PI 	11/10/2016 	Comprehensive Error Rate Testing (CERT)
Program: Medicare Administrative
Contractor (MAC) Certifying Official
12/12/2016 9846
R622PI 	10/30/2015 	Program Integrity Manual Chapter 12
Revision
12/07/2015 9391
R595PI 	05/22/2015 	Comprehensive Error Rate Testing (CERT)
Program Treatment of Power Mobility
Device (PMD) and Repetitive Scheduled
Non-Emergent Ambulance Transport Claims
in the Prior Authorization Model
06/23/2015 9156
R560PI 	12/12/2014 	Program Integrity Manual Chapter 12
Revisions
01/01/2015 8905
R504PI 	02/05/2014 	Revision to Chapter 12 of the Medicare
Program Integrity Manual - The
Comprehensive Error Rate Testing Program
03/06/2014 8591
R240PI 	02/08/2008 	Review the Fiscal Intermediary Shared
System (FISS) to Include All 11x Claims in
the Nightly Universe Files Generated for the
Comprehensive Error Rate Testing (CERT)
Program
04/07/2008 5915
R204PI 	05/25/2007 	Comprehensive Error Rate Testing (CERT)
Program Changes
06/25/2007 4120
R115PI 	07/22/2005 	PIM Revision – CERT Support Actions 	08/22/2005 3786
R077PI 	05/28/2004 	Comprehensive Error Rate Testing (CERT)
Requirements
06/28/2004 3229
R071PI 	04/09/2004 	Rewrite of Program Integrity Manual (except
Chapter 10) to Apply to PSCs
05/10/2004 3030
R067PI 	02/27/2004 	Comprehensive Error Rate Testing (CERT)
Requirements
03/12/2004 2976
R012PIM 09/20/2002 	Clarification & Manualization of Chapter 	N/A 	1143
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