Beacon

Prepayment Probe Review Process

Provider Specific

This type results from a high error rate from a postpayment probe.

Postpayment Results Letter:

  • Provider will receive a postpayment results letter notifying them a prepayment review will be initiated.

Additional Development Request (ADR):

  • Sent to providers requesting supporting documentation for services billed.

Prepayment Results Letter:

  • A quarterly results letter with a spreadsheet will be sent with review decisions. For complete denial rationale please contact the Provider Contact Center (PCC) 1-877-567-7271.

Corrective Action:

  • If the error rate is high the prepayment review will continue and your error rate will be calculated and re-evaluated.
  • As your error rate decreases and remains decreased, we will remove you from audit review.
  • However, should you show no continued improvement or your error rate increases, further corrective action(s) could result, such as an onsite audit, suspension of payment or referral to our Zone Program Integrity Contractor (ZPIC)

Education:

Widespread

Data Analysis:

  • Conducted to identify, analyze and determine potential inappropriate billing and program vulnerabilities.

Prepayment Probe Notification Article:

  • Posted in Cahaba’s “What’s New” Section informing providers of an upcoming Part B prepayment probe.

Additional Development Request (ADR):

  • Sent to providers requesting supporting documentation for services billed.

Prepayment Probe Results Article:

  • Posted in Cahaba’s “What’s New” Section informing providers of probe results.

Remittance Notices:

  • Provider will receive a remittance notice including each claim decision.
  • For complete denial rationale please contact the Provider Contact Center (PCC) at 1-877-567-7271.

Corrective Action:

  • If dollar error rates are high and billing patterns are not in compliance with CMS directives, the probe will be continued as a widespread targeted prepayment review.
  • If dollar error rates are low and billing patterns are within compliance with CMS directives a results article will be posted with educational material included on Cahaba’s “What’s New” section and the prepayment probe will be closed.

Education:

  • Was this page helpful?
  • Yes   No