Handling Overpayments and Underpayments Resulting from the

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.