Prepayment Medical Record Review Edits

3.4.2 – Prepayment Medical Record Review Edits (Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17) This section applies to MACs. The MACs shall focus prepayment medical record review edits to suspend only claims with a high probability of aberrant billing practices. Focused edits reduce provider burdens and increase the efficiency of MR activities. The MACs shall ensure that edits are specific enough to identify only the services that they determine to be questionable based on data analysis. MACs are encouraged to ensure that most MR edits are located in the table driven portion of the system and are not hard coded. It is important to have the flexibility to modify MR edits based on workload demands and changes in provider behavior. The MACs have the discretion to establish prepayment medical record review edits that are either service-specific or provider-specific. Provider-specific edits can suspend all claims from a particular provider or focus on selected service(s), place of service, or other parameters.