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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 A
Documentation Requirements
This web page has been specifically designed by Prepay Medical Review Part A to assist providers with fulfilling documentation requirements to support the services being billed and to provide a better understanding of the documentation needed to
adjudicate claims appropriately.
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.
Frequently Asked Questions
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.
Inpatient Rehabilitation Facility
This link to take you to our Part A IRF section which includes articles and links to information on subjects of IRF.
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.
Prepayment Review Edits
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.
Probe Review
This kind of Medical Review (MR) can be conducted on a PrePay or PostPay basis and can be Widespread or Provider Specific in scope. Submission of documentation is always required. This page discusses the differences between Widespread and
Provider Specific Probe Review.
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.
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.”
Skilled Nursing Facility
This link to take you to our Part A SNF section which includes articles and links to information on subjects of SNF.
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