decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Medicare_Carriers_Manual / 14004 / 14004.7_REFERRAL_TO_MEDICAL_REVIEW.-
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Article Overview
This Medicare Carriers Manual article explains when a provider may be referred to medical review and describes the broader use of prepayment and postpayment review as administrative responses to abusive billing behavior. It is relevant to Medicare compliance, utilization review, and payment integrity staff who need to understand the kinds of review actions discussed in the manual and the circumstances that may trigger them.
Why This Topic Matters
It helps readers understand a Medicare administrative process used to address billing concerns and payment risk. The article is useful for compliance, audit, and revenue integrity teams evaluating when medical review actions may be considered.
What You Will Learn
- How the Medicare carrier medical review referral process is described in the manual
- The general role of prepayment and postpayment review in handling billing concerns
- The administrative considerations associated with review actions and provider behavior
- The types of situations discussed as prompting referral to medical review
Who Should Read This
- Medicare compliance staff
- Medical coders
- Billing and revenue cycle staff
- Utilization review personnel
- Audit and integrity teams
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