Medical Review

Resumption of Postpayment Medical Reviews

As recently published at MACs Resume Medical Review on a Postpayment Basis, Medicare Administrative Contractors (MACs) have resumed fee-for-service medical review activities to protect the Medicare Trust Fund against inappropriate payments. Beginning on or after August 17, 2020, the MACs resumed with postpayment reviews of items and services provided before March 1, 2020.

You may receive an additional documentation request (ADR) requesting medical record documentation associated with a claim selected for a service-specific postpayment review. For more information about services under review and how to respond to an ADR, you may refer to the Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review and Active Service Specific Postpayment Medical Reviews articles.

Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints);
  • Reviews data analysis reports;
  • Takes action to prevent and/or address the identified error;
  • Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute

Additional Resources

Medical Review Articles

Targeted Probe and Educate Progress Update: JM 99291-99292: Critical Care First HourTargeted Probe and Educate Progress Update: JM Emergency E/M 99284-99285Targeted Probe and Educate (TPE) ProcessTargeted Probe and Educate Progress Update: JM Part B Ambulance A0427-A0429 Ambulance Services (Emergent)Targeted Probe & Educate (TPE) Provider ContactMedical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicTargeted Probe and Educate Progress Update: JM E/M 99232-99233: Subsequent Hospital CareTargeted Probe and Educate VideoMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsPalmetto GBA Partnering with Providers to Get it Right the First TimeOrders Issued Through Text MessagingOutpatient Therapy (OT) Exercises ChecklistHyperbaric Oxygen ChecklistWe Have Noticed a Significant Increase in 296 Auto Denials - Requested Records Not SubmittedCritical Care ChecklistAttestation StatementsErrors in Emergency Department ServicesMedical Review: Additional Documentation Requests (ADRs)MACs Resume Medical Review on a Post-Payment BasisOutpatient Department (OPD) Prior Authorization (PA) Alert!Outpatient Department (OPD) Prior Authorization (PA) Required DocumentationPrior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked QuestionsOutpatient Department (OPD) Prior Authorizations (PA)Outpatient Department Prior Authorization CalculatorOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberRhinoplastyOutpatient Department Prior Authorization (OPD) eServices Submission GuideBlepharoplasty and Blepharoptosis RepairPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewOutpatient Department (OPD) Prior Authorization (PA) ExemptionWe Have Noticed a Significant Increase in 56900 Auto Denials - Requested Records Not SubmittedActive Service Specific Postpayment Medical ReviewsPart B Reason Code CrosswalkTop Medical Review Denials ModuleCharge Denial Rate (CDR) CalculatorADR Response CalculatorReceiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewVein Ablation and Related ServicesThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideComplying with Medicare Signature RequirementsDocumentation Tips for Ambulance Providers: Paint the PictureMedical Review Program and Targeted Probe and Educate HandoutMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesTargeted Probe and Educate Process ModuleAmbulance Suppliers of Repetitive Scheduled Non-Emergent TransportsAdministrative Relief in Response to the 2019-Novel Coronavirus (COVID-19) Pandemic: Pausing Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization ModelAmbulance Prior Authorization RemindersAmbulance Fee Schedule and Medicare Transports CMS BookletUpdate: Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance TransportPrior Authorization of Repetitive Scheduled Non-Emergent Ambulance TransportsFrequently Asked Questions: Prior Authorization (PA) Repetitive Scheduled Non-Emergent Ambulance TransportsLetter for Patients with a Legal Representative for Repetitive Scheduled Non-Emergent Ambulance Transport Prior AuthorizationPhysician Compliance: Ambulance Prior Authorization DocumentationAmbulance Prior Authorization Request FormEnhanced eServices Ambulance Prior Authorization FormPhysician/Practitioner LetterBeneficiary Non-Affirmation Letter for Ambulance Prior AuthorizationAmbulance MileageAmbulance Prior Authorization eServices Form (HCPCS A0427, A0429) ModuleNon-Affirmed Code Crosswalk: Prior Authorization RequestAmbulance Prior Authorization Documentation Decision ToolJurisdiction M Part B Prior Authorization Extended Affirmation Teleconference Questions and Answers: August 14, 2019Important Lessons Learned About the Repetitive Scheduled Non-emergent Ambulance Prior Authorization ModelIf Your Medicare Patient Requires Scheduled Repetitive Non-Emergent Ambulance Transport, This Is Information You Need to KnowRelease of Beneficiary Information to Ambulance Providers of Repetitive Scheduled Non-Emergent TransportsAccess TPE Letters Electronically Job AidesMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)Medicare Record Authentication: Tips for PhysiciansWe're All In This Together Flyer - Wound Care Facilities (WCF)We're All In This Together Flyer - Dialysis FacilitiesPanniculectomyBotulinum Toxin InjectionsSurgical DebridementOutpatient Department (OPD) Prior Authorization (PA)ADRs for Outpatient Department Prior Authorization services (OPD PA) Services