Postpay Service Specific Probe Medical Record Review

7.2.2.11 - Postpay Service 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 service 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 in the case of a possible service/systemic problem, the contractor should generally include a random or stratified sample of 100 claims with dates of service from the period under review from across all providers or suppliers that bill the particular item or service in question. 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 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.