Providing Feedback Information to the CERT Review

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.