US · guidance
CMS Pub. 100-08, ch. 7, § 7.2.2.11
Postpay Service Specific Probe Medical Record Review
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.
History
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
c40d9420ecdbfb2179a487a9b87924510a51edc42bf937a0d79cf25faf39898d
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.