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Medical Review

Noridian Medical Review staff conducts medical record reviews according to the CMS guidelines in the CMS Intenet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 This link will take you to an external website.. Noridian's goal is to reduce the contractor's claim 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. Reviews are based either on CMS requirements or data analysis findings. MR reviews specific data findings, trend analysis reports, edit evaluation reports, national comparison reports, over utilization reports and Comprehensive Error Rate Testing (CERT) reports. This information is evaluated and a determination is made of the type of reviews to be performed.

Data analysis findings in conjunction with the data source reasons are reviewed and prioritized accordingly, assisting in determination of the appropriate type of review.

Types of Reviews

Review Brief Description
Advance Determination of Medicare Coverage Section 1834(a)(15)(C) of the Social Security Act provides that carriers shall, at the request of a supplier or beneficiary, determine in advance of delivery of an item whether payment for the item may not be made because the item is not covered if:
  • Item is a customized item,
  • Patient to whom item is to be furnished, or supplier, requests that such advance determination be made, and
  • Item is not an inexpensive item as specified by the Secretary

Complex Review

Service Specific Post-Payment Reviews - Currently, Noridian DME Medical Review does not have any active Post-Payment Reviews.

Service Specific Pre-Payment Reviews - Service Specific Pre-Pay Reviews conducted by Noridian DME Medical Review are used to determine the extent of potential problem areas across multiple suppliers and monitor corrective action measures implemented to reduce improper payments.

Non-Complex Review

Non-Complex Medical reviews conducted by Noridian DME are used to determine the extent of potential problem areas across multiple DME product classifications, and monitor corrective action measures implemented to reduce improper payments.

Prior Authorization On September 1, 2012, CMS implemented a Prior Authorization Request (PAR) process for designated Power Mobility Devices (PMDs) for Medicare beneficiaries residing in seven high population states including California, Illinois, Michigan, New York, North Carolina, Florida, and Texas.

On October 1, 2014, the PAR demonstration expanded to an additional twelve states including Washington, Missouri, Arizona, Pennsylvania, Maryland, New Jersey, Indiana, Louisiana, Tennessee, Georgia, Ohio and Kentucky.

On September 1, 2015, the PAR demonstration was extended for an additional three years and will end August 31, 2018. See Prior Authorization of PMD Demonstration on the CMS website.
Supplier Transition to Exclusion Program (STEP) STEP is a voluntary educational program offered to Hospital Bed and continuous positive airway pressure (CPAP) suppliers in Jurisdiction A. A Medical Review Nurse will provide suppliers with necessary educational resources and individualized education to independently complete self-audits in efforts to reduce error rates and increase reimbursement.


Accessing Medical Review Decisions

Learn how you can access the Noridian Medical Review Examiner's decisions following their review of submitted documentation to support the processing of a claim within the Noridian Medicare Portal.

Benefits of MR

MR initiatives are designed to ensure that Medicare claims are paid correctly. MR offers many benefits to providers while helping to maintain the integrity of the Medicare Program.

  • Reduced Medicare claims payment error rate – The MR program identifies and addresses billing errors concerning coverage and coding by providers, thus reducing the overall claims payment error rate
  • Decreased denials – Knowledge of the appropriate claim guidelines may result in a reduction in filing errors and an increase in timely payments
  • Increased educational opportunities – Medicare provides education on claims that are denied through MR. Contractors also issue articles and other informational materials. The educational processes provided by Medicare help providers know what to expect when a claim is submitted to Medicare for payment


Last Updated Nov 03, 2016

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Last Updated Jun 08, 2016