Medical Review

Medical Review (MR) initiatives are designed to ensure that Medicare claims are paid correctly. MR offers many benefits to suppliers while helping to maintain the integrity of the Medicare Program.

  • Reduced Medicare claims payment error rate - MR program identifies and addresses billing errors concerning coverage and coding by suppliers, 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 - MR and Provider Outreach and Education (POE) provides education on claims that are denied through MR, in addition to issuing articles and other informational materials. The educational processes provided help suppliers know what to expect when a claim is submitted to Medicare for payment

Medical Record Reviews

Claim Review Preparation - When a Medicare claim requires additional information, Noridian will send an Additional Documentation Request (ADR) letter requesting the supplier send information to support the claim being billed.

Responding to the ADR - Noridian has established multiple claim review submission processes for suppliers to utilize in response to ADR letters.

Accessing Medical Review Decisions - The Noridian Medicare Portal (NMP) offers access to view claim processing comments if a claim had been selected for prepayment review in which Noridian requested documentation prior to making a claim decision.

Medical Record Review - Notifications and Results - Service Specific Post-Payment Reviews and/or Pre-Payment Reviews used to determine the extent of potential problem areas across multiple suppliers and monitor corrective action measures implemented to reduce improper payments.

Non-Medical Record Review - Notifications and Results - Non-Medical Record reviews used to determine the extent of potential problem areas across multiple durable medical equipment (DME) product classifications, and to monitor corrective action measures implemented to reduce improper payments.

Targeted Probe and Educate (TPE) - CMS has authorized Durable Medical Equipment Medicare Administrative Contractors (DME MACs) to conduct the TPE review process. View information regarding the review.

Pre-Claim Reviews

Advance Determination of Medicare Coverage (ADMC) - Information about the voluntary program that allows Suppliers and Beneficiaries to request prior approval of "eligible" items before delivery of the items to the beneficiary.

Prior Authorization - CMS implemented program for specific HCPCS codes.

 

Last Updated Jan 22, 2018

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