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Postpayment Review Process

Program Integrity Manual (CMS Pub. 100-08), Ch. 3, §3.6 Globe to indicate www link.

A postpayment review is a comprehensive review of individual beneficiary medical records. This review of records may be conducted either onsite at your facility or may be done in the Medicare contractor’s Medical Review Department. The purpose of the review is to determine the provider's compliance with Medicare guidelines and regulations. Medical review nurses use the most recent data available for specific billing periods. The time spent during a postpayment medical review is an opportunity to educate providers with regard to correcting identified problems and preventing future problems.

Types of postpayment review include:

  1. Error Validation Review, also known as 'probe' review

Nurse reviewers generally use the most recent four-to-six month billing records. This type of review does not allow for projection of overpayments to the universe of claims reviewed. Overpayments are collected only on claims that are actually reviewed, determined to be noncovered, and where the provider is liable or at fault for the overpayment.

  1. Statistical Sampling Review

This type of review does require that a statistically valid random sample be used to identify and project over payments to the universe of claims reviewed.

Page last updated: April 8, 2008

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