CMS Pub. 100-08, ch. 7, § 7.2.2

The reporting process will require data that can be classified under three different

categories of activity measures: Workload, Cost, and Savings. The Medical Review

definitions shall apply to all Medical Review activities and shall not be deviated from or

interpreted differently than stated below. The consistency in the application of these

definitions will provide validity to the data reported that is required to assess the

effectiveness of the CMS Medical Review and Education Program being administered by

the Contractor(s)

MEDICAL REVIEW

The review of claims and associated medical documentation that occurs when review

staff:

1. Make a coverage decision (benefit category, statutory exclusion, or reasonable

and necessary) and a coding decision to determine the appropriate payment for

claims, or

2. Investigate complaints to determine whether a corrective action was effective

(e.g., an MR activity such as provider notification letter), or identify situations

that require prepayment edits or the development of a local coverage

determination (LCD).

The medical review process requires the application of clinical judgment either as part of

a review, in writing policies, or in the development of guidelines and processing

instructions. For local medical review edits, input must be from the Contractor Medical

Review clinicians/staff. For national edits, input from the Contractor medical/clinical

staff is not necessary. The medical review can be performed either before or after the

claim has been paid. Generally, a line cannot result in medical review workload or

savings if it is not referred to medical review. A line that potentially involves both

medical review and claims processing work should suspend to a claims processing

reviewer, and that reviewer should refer the line to medical review only if the claims

processing reviewer cannot make a decision based on guidelines available to that

reviewer.

Do NOT consider the review as medical review if it requires:

1. Pricing Only, or

2. Coding Only, or

3. Pricing and Coding only.

Consider the review as medical review if:

1. Pricing is based on medical record review determination. or

2. Coding is based on medical record review determination, or

3. Coding and Pricing are based on medical record review determination.

If an automated claims processing edit has already made a decision to pay, and the claim

only suspends for pricing, consider the review automated claims processing and do not

count it for medical review workload or costs.