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.
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 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.
|Cross Recovery|| |
When Medical Review performs reviews that result in long-standing high error rates, the MAC may request CMS approval to deny other related claims submitted before or after the claim in question.
Non-complex reviews occur when the MAC, CERT, Recovery Auditor, or ZPIC makes a claim determination without clinical review of medical documentation submitted by the provider.
|Probe||When Noridian identifies a provider or service as being at risk, the potential error is validated with a prepayment probe (error validation) review. Conducting a probe review ensures that medical review activities are targeted at identified problem areas. Probe reviews are designed to obtain a sample large enough to provide confidence in the result, but small enough to limit administrative burden.|
|Provider Self-Audit with Validation and Extrapolation (PSAVE)|| |
CMS pilot program which allows participants to perform their own self-audit, allow Noridian to validate the review findings and extrapolate on identified overpayments or determine underpayments.
Routine review requires hands-on review of the claim and/or claims history file by Noridian personnel utilizing 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 or CPT codes.
|Targeted||Targeted reviews are 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.
- Automated Development System (ADS) Submissions
- Dear Ordering/Referring Physician [PDF]
- Documentation Requirements/Checklists
- Electronic Submission of Medical Documentation (esMD)
- Evaluation and Management (E/M)
- Medical Review Frequently Asked Questions (FAQs)
- Medical Scribes
- MR Relationship with Provider Outreach and Education (POE)
- Progressive Corrective Action (PCA)
- Signature Requirements
- CMS MR, NCCI Edits, MUEs, CERT, and RAC Booklet
Last Updated Sep 30, 2016
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Last Updated Jul 30, 2015