US · guidance
CMS Pub. 100-08, ch. 7, § 7.2.2.7
Prepay Provider Specific Probe Medical Record Review
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.
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
84292f969cfb950096ba16f4a627671a43e4e2376e0ff1f36c0f74cd627a5a0e
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