Medical Review

The Medical Review (MR) 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 following summarizes the different activities performed by the Medical Review Department.

• Prepayment Review occurs when Fiscal Intermediary Standard System (FISS) edits suspend a claim for medical review before the claim is paid.
• Providers that have claims selected for prepayment review will receive an Additional Development Request (ADR) notice via the Fiscal Intermediary Standard System (FISS).
• Medical Review Denial Reason Codes explain the reason home health and hospice services are denied based on medical review decisions.
• Postpayment Review is a comprehensive review of individual beneficiary medical records, conducted either onsite at your facility or done in the Medicare contractor’s Medical Review Department.
• Progressive Corrective Action (PCA) provides Medicare contractors with further guidance, underlying principles and approaches to be used in deciding how to deploy resources and tools for Medical Review. 
• Comparative Billing Reports compare your facility to your state and to the total claims processed by Cahaba for specific dates of service.

Comprehensive Error Rate Testing (CERT) Program
The goal of the contractor’s MR Program is to reduce the contractor’s claims payment error rate by identifying, through analysis of data and evaluation of other information, program vulnerabilities concerning coverage and coding made by individual providers and by taking the necessary action to prevent and address the identified vulnerabilities.

Page last updated: May 5, 2010

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