Skip over navigation

Medical Review

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 This link takes 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.

Review Brief Description
Automated Prepayment When prepayment review is automated, decisions are made at the system level, using available electronic or claim system information, without the intervention of Noridian personnel. Reviews may be automated with clear policies such as Local Coverage Determinations (LCD) or National Coverage Determinations (NCD).
Complex

Complex medical review involves the evaluation of the provider's medical records and the application of clinical judgment by a licensed medical professional. Medical records include any medical documentation, other than what is included on the face of the claim that supports the billed service. Complex review is completed as either a prepayment review or a postpayment review.

  • Pre-payment Review - Includes a claim review, reasonable and necessary review, and/or coding review, which will be made before the initial claim payment.
  • Post-payment Review - Includes reasonable and necessary review, and/or coding review that is performed after claim payment. The postpayment determination either affirms payment of a claim (in full or in part), or denies payment and assesses an overpayment. Postpayment MR of claims may result in no change to the initial determination or may result in a revised determination.
Documentation Compliance Documentation Compliance Reviews are nonclinical, technical reviews to evaluate the presence or absence of particular pieces of documentation. Specific medical document(s) are requested. Review of the requested documentation is based on accuracy in completing all CMS requirements in a timely manner.
Probe Reviews initiated to validate potential errors for at risk providers and services while limiting administrative burden.
Routine Prepayment Routine review requires hands-on review of the claim and/or claims history file by Noridian personnel using the Medicare online claim system. The review is completed without review of provider medical records.
Service Specific In accordance with CMS Progressive Corrective Action (PCA) Plan, Noridian performs prepayment reviews which encompass service specific reviews for multiple providers regarding a particular service such as HCPC codes, Diagnosis Related Groups (DRGs), or CPT codes.
Targeted Reviews initiated based on error validation findings and the identification that additional review and education will assist in the correction of provider behavior and prevent future inappropriate billing.
Targeted Probe & Educate with Extrapolation (TPEE)

CMS pilot program which includes three rounds of a prepayment probe review with education. If there are continued high denials after the first three rounds, Noridian has the option to perform a fourth round, which will include a postpayment review with extrapolation.

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

Provider Rights During a Medical Review

A provider has the right, following MR, to be educated on how to bill correctly and to have questions answered in a timely manner. The provider also has the right to appeal determinations, as long as the appeals are filed in accordance with regulations governing that process.

Resources

Last Updated Oct 27, 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 May 04, 2015