Noridian Medical Review staff conducts medical record reviews according to the CMS guidelines found in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 . 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 Medical Reviews
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.
|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: |
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 Jul 20, 2016
CPT and ADA End User License Agreement for Providers
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.
CPT codes, descriptors and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
Last Updated Feb 03, 2015