decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Program_Memos / 2003 / B-03-008
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Article Overview
This memorandum describes CMS guidance for contractors and standard system maintainers working on medical review progressive corrective action functionality. It focuses on the broad system capabilities, data collection, and transfer-file formats needed to support prepayment sampling, claim suspension, tracking, and related reporting for Medicare review workflows. The article is relevant to Medicare contractors, system maintainers, and coding/billing operations staff involved in medical review system changes.
Why This Topic Matters
It helps readers understand which Medicare system and reporting functions were being required for progressive corrective action implementation, and which organizations and contractor environments were affected.
Article Sections
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Program Memorandum
Introduces the memorandum, issuing organizations, transmittal information, date, and the change request context.
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Subject and background
Summarizes the purpose of the memorandum and its relationship to earlier work on medical review corrective action.
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Approach to implementing PCA
Describes the general system capabilities and operational functions contractors and maintainers were expected to support.
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Provide needed information to track providers
Outlines the categories of statistical and tracking information the system had to make available for review activities.
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Attachment: Formats
Presents the structure of the transfer file formats used for reporting and tracking within the review process.
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Format for the PCA Transfer File
Defines the layout for the PCA transfer file and its data elements.
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Format for the E&M Code File
Defines the layout for the file used when evaluation and management coding is part of the study criteria.
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Format for the ICN File
Defines the layout for the file used to identify selected claim records in the sample.
What You Will Learn
- The purpose and scope of CMS guidance for medical review progressive corrective action.
- Which Medicare system environments and contractor groups were implicated.
- The general categories of sampling, suspension, tracking, and reporting support discussed in the memorandum.
- The types of attachment file formats included for implementation support.
Who Should Read This
- Medicare contractors
- Standard system maintainers
- Data center personnel
- Medical review operations staff
- Billing and claims processing staff
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