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What Is Medical Review?
The Centers for Medicare and Medicaid Services (CMS) is required by the Social Security Act to ensure payment is made only for those services that are reasonable and necessary in order to protect the integrity of the Medicare Trust fund.
Articles
This section of our web site contains articles written about subjects of Medical Review and Local Coverage Decisions.
Prepay Medicare Review Part B
Documentation Requirements
This web page has been specifically designed by Prepay Medical Review, Part B, for providers to offer assistance regarding the documentation requirements Medicare needs to adjudicate your claims. The intent is to provide education and information on
the medical review process and to explain why the carrier may request copies of medical documentation from providers in carrying out medical review activities. A link to all PrePay audits implemented by the carrier (except provider specific audits) are
listed on this web page.
Probe Review
Medical Review will perform a widespread probes in all states. The results of the probe will be shared with the Carrier Medical Directors for use in evaluating the effectiveness of the current LCD. The Local Provider
Education and Training (LPET) team will educate providers if indicated by the results of the probe review. Requirements to comply with request for additional documentation are listed.
CMS Online Manual System
The CMS online manual system is a good source of technical and professional information about the Medicare and Medicaid programs.
CMS Program Transmittals
Program transmittals are used to communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS program manual.
Documentation Submission Tips
This page provides 10 tips for submission of Medical Review Documentation.
How Can I As A Provider Be Proactive?
The purpose of Medical Review is to assist the medical community in the reimbursement of covered care with a minimum of inconvenience and dollar expenditure. So, how can you help and lessen your frustration? This page will provide
detailed information.
ICD-9 codes for Anti-Cancer Drugs
Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the
following anti-cancer drugs may be billed with the specified diagnosis codes
only, as of 01/01/2007.
Prepayment Review, Edits And Audits
This consists of Medical Review performed prior to payment and may or may not require submission of records. This may involve a system edit to prevent payment for non-covered and/or improperly coded services. This page
displays types of prepay reviews.
Progressive Corrective Action Process (PCA)
Simply put, this is how Medical Review is conducted! The process and concepts are available online in Chapter 3 of the Program Integrity Manual. This page discusses each step.
Frequently Asked Questions
Medical Policy
This link will take you to our Medical Policy information which includes: Final, Draft, and Retire Medical Policies. It also includes our opening meeting dates, and reconsideration process information.
Self Administered Drugs
As required by the Centers for Medicare and Medicaid Services (CMS), Medicare Services has developed the following list of drugs that are excluded from coverage because they meet the CMS definition of
“self-administered.”
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