CMS Updates CERT Rules on ADR Response Timelines and Overpayment Recovery

• By: Maureen Carland
• On: 08/05/2026 10:54:44
• In: Quality/Regulatory

CMS has issued Transmittal R13890PI (CR 14539), revising Chapter 12 of the Medicare Program Integrity Manual (Pub. 100-08) governing the Comprehensive Error Rate Testing (CERT) program, effective August 28, 2026. The changes streamline how MACs handle claims with no response or insufficient response to Additional Documentation Requests (ADRs) and clean up related overpayment recovery language.

Notably, the "No Response to ADR" and "Insufficient Response to ADRs" sections have been renumbered (now 12.10.1 and 12.10.2, respectively), and the prior section on potential fraud investigations has been deleted entirely, as it no longer applies to CERT's improper payment review process. For error code 99 claims (no documentation received within 60 days), CMS clarified that regardless of which option a MAC selects for handling the claim, feedback must be completed at least 30 days before the deadline for submitting late documentation — closing a gap that previously allowed collection within 10 business days of that deadline. The transmittal also updates the CERT Documentation Center's mailing address, email, and fax number on the Unified Post-payment ADR Sample Letter (Exhibit 46.4), so facilities responding to ADRs should note the new contact information.

While this transmittal is largely a technical/administrative update for MACs, facilities should be aware of the tightened feedback timeline and updated submission contacts the next time they're responding to a CERT ADR.
 
Staff contact: mcarland[at]mehca.org