CMS Pub. 100-08, ch. 7, § 7.2.2.8

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.

7.2.2.9 - Advance Determination Medicare Coverage (ADMC)

(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);

Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013

(Implementation of VMS)

At the request of a supplier or beneficiary, the DME MAC may determine in advance of

delivery of an item whether payment for that item is medically necessary. The request

must contain adequate information from the patient’s medical record to identify the

patient for whom the item is intended, the intended use of the item, and the medical

condition of the patient that necessitates the use of the item.