Providing Sample Information to the CERT Review Contractor

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.