Postpay Provider Specific Probe Medical Record Review

7.2.2.10 - Postpay Provider Specific Probe Medical Record Review (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) Medical record review requires a licensed medical professional to use clinical review judgment to evaluate medical records. Postpay provider specific probe medical record reviews are done to verify that the program vulnerabilities identified through data analysis actually exist and will require education and/or further medical review. For postpay review of an individual provider in the case of a possible provider specific problem, contractors shall include in the probe sample a random or stratified sample of generally 20 -40 claims from that provider with dates of service from the period under review. The Contractor shall validate data analysis findings by conducting probe reviews and implementing the necessary PCAs in accordance with, IOM Pub. 100-08 Chapter 3. Once a problem has been verified, the Contractor shall implement the necessary PCA. This includes providing the initial notification informing the provider of the results of the probe review, and collaborating with Provider Outreach and Education (POE) to share potential educational needs, and making referrals to POE, UPICs, RACs or others as appropriate.