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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 or it may involve edits that
suspend claims for Medical Review. There are several types of prepay review:
Automated:
In this type of review, the decision is made at the system level without the
intervention of a medical reviewer. An example of this would be issues
concerning the relationship between diagnosis and HCPC’s codes that are being
billed. The diagnosis’s that are covered from the LCD pertaining to the service.
If a claim is rejected by the system because of the diagnosis, the provider can
then submit additional documentation to substantiate the payment of the claim.
Complex Review:
This type of review requires development of the medical records with an ADR
letter and the evaluation of documentation submitted. This requires a clinician
who has a working knowledge of coverage and LCD’s.
Edits:
There are two types of prepay edits – services specific and provider
specific. As we develop this web site and particularly the Medical Review
Webpage, the intent is to provide direct links for the provider to access each
edit for information about the purpose and required documentation.
Service Specific Edit:
These edits originate from data analysis that identifies a problem. The
criteria (Revenue codes, HCPC’s codes, Diagnosis’s) that are needed to capture
the claims to be examined are put in the system. The documentation requirements
based on the LCD appears as an external narrative in the FISS system. The system
then suspends the claims and an ADR is sent to the provider requesting specific
documentation. The medical reviewer reviews the medical records that are sent
and makes a determination as to whether it meets criteria for medical necessity
and if the documentation supports the billed services.
Provider Specific Edit:
This is also a result of data analysis and may suspend all claims for a
provider who has demonstrated unusual practice patterns. Documentation is
requested with an ADR and the claim may be denied or paid, depending on whether
the documentation supports the service billed.
Edit Monitoring:
Regardless of the type of edit, each edit implemented is evaluated at least
quarterly for effectiveness. Edits are taken down when the denial rate falls to
20% or less. Provider response to correct problems expedites removal from the
edit and all results and recommendations are shared with CMS. It should be noted
that all edits begin and end with data analysis and are driven by the PCA
process. |
