Prepay Provider Specific Probe Medical Record Review

7.2.2.7 - Prepay 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. Prepay probe medical record reviews are done to verify that the program vulnerability identified through data analysis actually exists and will require education and possible targeted medical record review. In the case of a possible provider specific problem, contractors should generally use a sample of 20 -40 claims submitted by that individual provider. 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.