Postpayment Probe Review Process

Data Analysis

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

Postpayment Notification Letter

  • Sent to provider to inform them they have been selected for postpayment claims review along with a comparative billing report showing the provider a comparison of their billing to other providers billing and informing them they are above average for their specialty.

Additional Development Request (ADR)

  • Sent to provider requesting supporting documentation for claims included in the probe review, which are specified in the postpayment notification letter.

Postpayment Claims Review

Postpayment Results Letter

  • Sent to provider with results of postpayment claims review.

Corrective Action

  • If dollar error rates are high and billing patterns are not in compliance with CMS directives, the provider will be put on prepayment review for the next quarter.
  • If dollar error rates are low and billing patterns are within compliance with CMS directives, the provider will receive a letter with results.


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