Medical Review Overview

Our primary mission is to reduce provider billing errors by identifying patterns of inappropriate billing, reviewing claims, and educating providers on medical review claim determination findings. Our primary goal is to pay claims correctly the first time.

We use multiple data sources to identify patterns of inappropriate billing. This includes both data of provider billed claims and errors identified by other CMS contractors. See Other Review Contractors

Once you are identified for a medical review we will notify you. Notification is completed one of two ways:

  • Provider Specific Reviews: A review only completed on the provider's facility for a specific identified service
    • Notice is provided by individual provider letter
  • Service Reviews: Review includes provider and other facilities on the same service that was identified as potentially in error
    • Notice is provided on our website

Our plan and philosophy for education is to educate early and often. The ultimate goal of education is to reduce any claim errors identified during a review. We may complete this education in multiple methods and frequency. 

See the CMS Medical Review and Education webpage for more detail on the MR program overview.
 

Last Updated Aug 01, 2018