The Medical Review Program is designed to promote a structured approach in the interpretation and implementation of Medicare policies. CMS makes it a priority to automate this process; however it may require the evaluation of medical records to determine the medical necessity of Medicare claims. The goal of the MR Program is to reduce the contractor’s payment error rate by identifying patterns of inappropriate billing through data analysis, performing medical review of claims and developing local policies to address program vulnerabilities. MR reviews specific data findings, peer comparison reports, trend analysis reports, national comparison reports, over utilization reports, and Comprehensive Error Rate Testing (CERT) reports. This information is reviewed and evaluated to determine the types of reviews to perform.
Medicare policies are used by the contractor to apply Medicare coverage guidelines. These policies are generally divided into National Coverage Determinations (NCDs), coverage provisions in interpretive manuals, and Local Coverage Determinations (LCDs).
NCDs are developed by the Centers for Medicare & Medicaid Services (CMS) to describe the circumstances for Medicare coverage nationwide for a specific medical service procedure or device. For more information on these provisions, please visit the CMS NCD Web site.
Coverage provisions in interpretive manuals are instructions that are used to further define when and under what circumstances services may be covered (or not covered). For more information on these provisions, please visit the CMS Web site .
LCDs are decisions by a contractor whether to cover a particular service on a contractor wide basis in accordance with Section 1862 (a)(1)(A) of the Social Security Act (i.e. reasonable and necessary). For more information on LCDs, visit our LCD Homepage.
Page last updated:March 8, 2012