Prepay Service Specific Probe Medical Record Review

7.2.2.8 - Prepay 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. Prepay service specific 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 review. For Prepay review in the case of a possible systemic problem, the contractor shall include a random or stratified sample of generally 100 claims submitted 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.