Program_Memos / 2002 / B-02-078

Why This Topic Matters

It documents CMS implementation expectations for contractor systems and data extracts tied to medical review operations, making it useful for organizations that manage Medicare claims processing and compliance workflows.

Article Sections

1. Change Request and Subject

   Introduces the memorandum, its release date, and the overall implementation topic for Medicare contractor systems and medical review operations.

2. Background and implementation scope

   Summarizes the affected contractor environments, the overall purpose of the update, and the broad system capabilities expected for implementation.

3. Approach to Implementing PCA

   Describes the general framework for implementing the progressive corrective action process, including sampling, review handling, and related system support.

4. Provide needed information to track providers

   Lists the categories of reporting and tracking information the system must produce for contractor use in medical review oversight.

5. Attachment A: Format for the PCA Transfer File

   Provides the structure of the transfer file used to support reporting from the PCA process and the associated data elements.

6. Format for the E&M Code File

   Outlines the file format for reporting evaluation and management code review information within the PCA process.

7. Format for the ICN File

   Outlines the file format for identifying claims included in the sample through claim-level tracking fields.