CPMA 2026 ALL TESTED QUESTIONS AND ANSWERS
SURE A+
✔✔CERT randomly selects a - ✔✔Statistically valid sample of processed Medicare FFS
claims, and requests medical documentation from the provider or supplier that
submitted the sampled claim.
✔✔CERT performs a complex - ✔✔Medical Review of the claim and the supporting
documentation to determine whether the claim was paid appropriately according to
Medicare coverage, payment, coding, and billing rules.
✔✔CERT - ✔✔Comprehensive Error Rate Testing
✔✔CMS calculates a national Medicare FFS improper payment rate and improper
payment rates by service type to - ✔✔Accurately measure the performance of the Macs
and gain insight into the causes of error. CMS publishes the results of these reviews
annually.
✔✔The FFS Improper Payment Rate is a good indicator of - ✔✔How claim errors in the
Medicare FFS Program impact the Medicare Trust Fund.
✔✔The 5 error categories that CERT contractors identify - ✔✔*No documentation
*Insufficient documentation
, *Medical Necessity
*Incorrect coding
*Other
✔✔No documentation - ✔✔Provider or supplier fails to respond to repeated requests for
the medical records or they do not have the requested documentation
✔✔Insufficient documentation - ✔✔Submitted medical documentation is inadequate to
say payment for the services billed; the CERT contractor reviewers could not conclude
that the billed service was actually provided, was provided at the level billed and/or was
medically necessary; or a specific documentation element that is required as a condition
of payment is missing
✔✔Medical necessity - ✔✔There is adequate documentation in the medical records to
make the informed decision that the services billed were Medically necessary based
upon Medicare coverage and payment policies.
✔✔Incorrect coding - ✔✔Provider or supplier submit s medical documentation
supporting
*a different code than was billed
*the service was performed by someone other than the billing provider or supplier
*the billed service was unbundled
*a beneficiary was discharged to a site other than the one coded on a claim
✔✔Claims selected for CERT Review are subject to potential - ✔✔Postpayment
denials, payment adjustments, or other actions depending upon the result of the review.
Normal appeal rights and processes apply.
✔✔CERT reviews have the following corrective actions - ✔✔*Improving system edits
*Increasing and focusing medical review on problem areas
*Updating coverage policies and manuals
*Conducting provider education efforts
✔✔Recovery Audit Program is performed by - ✔✔Medicare FFS Recovery Auditors
Complexity : Complex
✔✔Recovery Auditors - ✔✔Review past Medicare FFS claim data for potential
overpayments or underpayments, reviewing medical records when necessary to make
appropriate determinations.
✔✔Recovery Auditors follow - ✔✔Medicare regulations, billing instructions, National
Coverage Determinations (NCD), coverage provisions, and the respective Mac's Local
Coverage Determinations (LCDs).
SURE A+
✔✔CERT randomly selects a - ✔✔Statistically valid sample of processed Medicare FFS
claims, and requests medical documentation from the provider or supplier that
submitted the sampled claim.
✔✔CERT performs a complex - ✔✔Medical Review of the claim and the supporting
documentation to determine whether the claim was paid appropriately according to
Medicare coverage, payment, coding, and billing rules.
✔✔CERT - ✔✔Comprehensive Error Rate Testing
✔✔CMS calculates a national Medicare FFS improper payment rate and improper
payment rates by service type to - ✔✔Accurately measure the performance of the Macs
and gain insight into the causes of error. CMS publishes the results of these reviews
annually.
✔✔The FFS Improper Payment Rate is a good indicator of - ✔✔How claim errors in the
Medicare FFS Program impact the Medicare Trust Fund.
✔✔The 5 error categories that CERT contractors identify - ✔✔*No documentation
*Insufficient documentation
, *Medical Necessity
*Incorrect coding
*Other
✔✔No documentation - ✔✔Provider or supplier fails to respond to repeated requests for
the medical records or they do not have the requested documentation
✔✔Insufficient documentation - ✔✔Submitted medical documentation is inadequate to
say payment for the services billed; the CERT contractor reviewers could not conclude
that the billed service was actually provided, was provided at the level billed and/or was
medically necessary; or a specific documentation element that is required as a condition
of payment is missing
✔✔Medical necessity - ✔✔There is adequate documentation in the medical records to
make the informed decision that the services billed were Medically necessary based
upon Medicare coverage and payment policies.
✔✔Incorrect coding - ✔✔Provider or supplier submit s medical documentation
supporting
*a different code than was billed
*the service was performed by someone other than the billing provider or supplier
*the billed service was unbundled
*a beneficiary was discharged to a site other than the one coded on a claim
✔✔Claims selected for CERT Review are subject to potential - ✔✔Postpayment
denials, payment adjustments, or other actions depending upon the result of the review.
Normal appeal rights and processes apply.
✔✔CERT reviews have the following corrective actions - ✔✔*Improving system edits
*Increasing and focusing medical review on problem areas
*Updating coverage policies and manuals
*Conducting provider education efforts
✔✔Recovery Audit Program is performed by - ✔✔Medicare FFS Recovery Auditors
Complexity : Complex
✔✔Recovery Auditors - ✔✔Review past Medicare FFS claim data for potential
overpayments or underpayments, reviewing medical records when necessary to make
appropriate determinations.
✔✔Recovery Auditors follow - ✔✔Medicare regulations, billing instructions, National
Coverage Determinations (NCD), coverage provisions, and the respective Mac's Local
Coverage Determinations (LCDs).
