decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Medicare_Carriers_Manual / 4171 / 4171.2_Reports_from_PRO.--
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Article Overview
This article covers Medicare carrier handling of reports from a peer review organization (PRO) in the context of ambulatory surgical center claim adjustments. It is aimed at billing and reimbursement staff who need to understand the kinds of PRO findings that can trigger claim corrections, denials, recovery actions, or record updates. The material focuses on procedural handling, facility-charge implications, and the categories of PRO action indicators used in the exchange format.
Why This Topic Matters
It helps billing and claims personnel recognize when a PRO report requires follow-up on a facility claim and associated physician charges, and it clarifies the types of administrative actions that may follow a PRO review.
Article Sections
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PRO review adjustments and post-payment recovery
Explains how PRO review findings are transmitted and how carriers are expected to handle adjustment-related information. It also notes related follow-up on facility and physician charges.
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PRO action indicators
Lists the PRO action indicators and summarizes the broad categories of claim handling or record correction associated with each indicator. The section is organized around the data exchange fields used in the manual process.
What You Will Learn
- How PRO review findings are communicated in the carrier data exchange process
- What types of claim adjustments may follow a PRO report
- How facility-charge findings relate to associated physician claims
- Which broad categories of administrative outcomes are represented by PRO action indicators
Who Should Read This
- Medical coders
- Billing staff
- Claims processors
- Revenue cycle professionals
- Hospital outpatient and ambulatory surgery billing staff
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