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Medical Review

Noridian Medical Review staff conducts medical record reviews according to the CMS guidelines in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 This link will take you to an external website. . Our 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

Advance Determination of Medicare Coverage (ADMC) - View 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.

Medical Record Review - View Service Specific Post-Payment Reviews and/or Service Specific 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 - View Non-Medical Record reviews conducted by Noridian DME and 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 - CMS has implemented prior authorization as a condition of payment for specific HCPCS codes. View information regarding these items and their requirements.

Targeted Probe and Educate (TPE) Pilot - CMS has authorized Jurisdiction D to conduct the TPE Pilot review process. View information regarding the review.

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 Jun 27, 2017

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 2016 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

Last Updated May 16, 2017