Answer_Book / Medical_Review_of_Claims / 26_items_checked_in_prepayment_review

Why This Topic Matters

Understanding prepayment screening helps organizations anticipate claims that may be delayed or reviewed more closely and supports better compliance with Medicare payment review processes.

Article Sections

1. Prepayment screening overview

   Introduces Medicare prepayment screening and the general purpose of claim review before payment. Describes the use of automated triggers and subsequent human review at a broad level.

2. Common claim factors that trigger closer look

   Summarizes broad categories of claim characteristics carriers may screen for, including service appropriateness, frequency, diagnosis alignment, certification, and unusually high charges. Also notes that carrier systems may vary.

3. Services and situations subject to excessive-use review

   Lists types of services and circumstances that carriers must monitor when utilization appears excessive. Focuses on broad service categories across office, hospital, nursing facility, rehabilitation, and diagnostic settings.

4. Claims that always must be flagged

   Describes certain claim types that require mandatory review and identifies an additional category involving drug claims with unusual or non-indicated patterns. Mentions carrier review of providers under heightened scrutiny.