Medical Review

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).

Additional Development Request (ADR) & Appeals

Providers may receive Additional Development Request (ADR) letters requesting additional documentation.  By day 46, if the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely.  An appeal can be submitted for Medical Review to reopen the claim.

Current Prepayment Medical Review Log

The Prepayment Medical Review Log provides you with a list of the most current prepayment reviews being conducted by the Part B Medical Review Department.

Investigational Device Submission Requirements

The FDA assigns a special identifier number that corresponds to each device granted an Investigational Device Exemption (IDE).   Learn more about the claim submission requirements.

LCD Comment and Reconsideration Processes

LCDs that are in DRAFT are open for comment.  The LCD Reconsideration process is a mechanism by which interested parties can request a revision to a LCD.

Local Coverage Determination (LCD) & Articles

An LCD is a decision by a Medicare 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., a determination as to whether the service is reasonable and necessary). For a complete overview of LCDs, please go to the CMS Program Integrity Manual (Pub. 100-08), Chapter 13.

An Article is a tool to communicate certain information (e.g. billing, coding, etc.) to providers. Articles may include any newly developed educational materials, coding instructions or clarification of existing medical review related billing or claims policy. For a complete overview of Articles, please go to the CMS Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.

National Coverage Determinations (NCDs)

NCDs are developed by 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 website.

Coverage provisions in interpretive manuals are instructions that further define when and under what circumstances services may be covered (or not covered). For more information on these provisions, please visit the Manuals section on the CMS website.

Postpayment Probe Review Process

Provides an overview and how providers are selected for postpayment probe reviews.

Prepayment Probe Reviews Process

Provides an overview and how providers are selected for prepayment probe reviews..

Self-Administered Drug (SAD) Exclusion List

Medicare Contractors are responsible for making the determination concerning whether a given drug or biological is “usually self-administered”.  If the Contractor determines that a given drug is “usually self-administered,” it cannot be covered by Medicare under any circumstance, regardless of whether the drug is administered by a physician or anyone else.

Signature Requirements

Clarification for providers on how Medicare contractors review claims and medical documentation and outlines the new rules for signatures.


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