Automated Medical Review

7.2.2.1 - Automated Medical Review (Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17) A medical review is considered automated when a payment decision is made at the system level, using available electronic information, with no manual intervention. It must be based on guidelines for which the contractor’s Medical Review area has developed some or all of the logic for review of specific billing and coverage criteria based on vulnerabilities identified by the Contractor’s Medical Review area. This process is done completely through the Medical Review Contractors' technology developed in response to medical review data analysis.