Medical Review


Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints)
  • Reviews data analysis reports
  • Takes action to prevent and/or address the identified error
  • Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute

Additional Resources




Targeted Probe and Educate Progress Update: JM 99291-99292: Critical Care First HourTargeted Probe and Educate Progress Update: JM Emergency E/M 99284-99285Targeted Probe and Educate Progress Update: JM Part B Ambulance A0427-A0429 Ambulance Services (Emergent)Targeted Probe & Educate (TPE) Provider ContactTargeted Probe and Educate Progress Update: JM E/M 99232-99233: Subsequent Hospital CareTargeted Probe and Educate VideoMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsPalmetto GBA Partnering with Providers to Get it Right the First TimeOrders Issued Through Text MessagingOutpatient Therapy (OT) Exercises ChecklistHyperbaric Oxygen ChecklistWe Have Noticed a Significant Increase in 296 Auto Denials - Requested Records Not SubmittedAttestation StatementsErrors in Emergency Department ServicesOutpatient Department (OPD) Prior Authorization (PA) Alert!Outpatient Department (OPD) Prior Authorization (PA) Required DocumentationPrior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked QuestionsOutpatient Department (OPD) Prior Authorizations (PA)Outpatient Department Prior Authorization CalculatorOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberOutpatient Department Prior Authorization (OPD) eServices Submission GuideBlepharoplasty and Blepharoptosis RepairPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewWe Have Noticed a Significant Increase in 56900 Auto Denials - Requested Records Not SubmittedActive Service Specific Postpayment Medical ReviewsPart B Reason Code CrosswalkTop Medical Review Denials ModuleCharge Denial Rate (CDR) CalculatorADR Response CalculatorThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideMedical Review Program and Targeted Probe and Educate HandoutBeneficiary Non-Affirmation Letter for Ambulance Prior AuthorizationIf Your Medicare Patient Requires Scheduled Repetitive Non-Emergent Ambulance Transport, This Is Information You Need to KnowesMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)Botulinum Toxin InjectionsSurgical DebridementOutpatient Department (OPD) Prior Authorization (PA)ADRs for Outpatient Department Prior Authorization services (OPD PA) ServicesPanniculectomyPostpayment Service-Specific Probe Results for Drugs and Biological Services: Ranibizumab (Lucentis) for January through March 2021Postpayment Service-Specific Probe Results for Surgical Services, Extracapsular Cataract Removal with Insertion for January through March 2021Postpayment Service-Specific Probe Results for Ambulance Services (Emergent) for January through March 2021Postpayment Service-Specific Probe Results for Ambulance Services (Emergent) Advanced Life Support, Emergency Transport for January through March 2021CMS MLN Fact Sheet: Medical Record Maintenance and Access RequirementsCMS Physician Orders: Provider Minute VideoCervical Disc Spinal Fusion and Spinal Cord Stimulator On-Demand WebcastVein Ablation and Related ServicesHospital Outpatient Department (OPD) Prior Authorization Exemption ProcessMedical Review: Additional Documentation Requests (ADRs)Postpayment Service-Specific Probe Results for Rehabilitation Services: Therapeutic Exercises for April through June 2021Postpayment Service-Specific Probe Results for ESRD Monthly Capitation Payments (MCP) for April through June 2021Postpayment Service-Specific Probe Results for Ambulance Services (Emergent), Basic Life Support for April through June 2021Postpayment Service-Specific Probe Results for Drugs and Biological Services: Ranibizumab (Lucentis) for April through June 2021Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Column Chromatography, Mass Spectrometry for April through June 2021Postpayment Service-Specific Probe Results for Rehabilitation Services: Therapeutic Exercises for January through March 2021Postpayment Service-Specific Probe Results for Aflibercept (Eylea) for April through June 2021Postpayment Service-Specific Probe Results for Surgical Services, Extracapsular Cataract Removal with Insertion for April through June 2021Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests for April through June 2021Targeted Probe and Educate Resumed September 1, 2021Postpayment Service-Specific Probe Results for Ambulance Services (Emergent) for April through June 2021Postpayment Service-Specific Probe Results for Drugs and Biological Services: Denosumab (Prolia) for April through June 2021RhinoplastyAccess TPE Letters Electronically: Job AidPostpayment Service-Specific Probe Results for Surgical Services: Surgical Debridement for July through September 2021Postpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Extraction Removal with Insertion of Intraocular Lens Prosthesis for July through September 2021Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Drug Test def 22 Classes for July through September 2021Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Column Chromatography and Mass Spectrometry for July through September 2021Postpayment Service-Specific Probe Results for Diagnostic Services: Imaging, Echocardiography with Contrast in North Carolina, South Carolina, Virginia and West Virginia for July through September 2021Postpayment Service-Specific Probe Results for Outpatient Rehabilitation Services: Therapeutic Exercise for July through September 2021Ambulance Suppliers of Repetitive Scheduled Non-Emergent TransportsAmbulance Prior Authorization RemindersRelease of Beneficiary Information to Ambulance Providers of Repetitive Scheduled Non-Emergent TransportsNon-Affirmed Code Crosswalk: Prior Authorization RequestVein Ablation and Related Services ChecklistAmbulance Prior Authorization eServices Form (HCPCS A0427, A0429) ModuleTargeted Probe and Educate Process ModuleAmbulance Prior Authorization Documentation Decision ToolFrequently Asked Questions: Prior Authorization Repetitive Scheduled Non-Emergent Ambulance TransportsPostpayment Service-Specific Probe Results for Drugs and Biological Services: Ranibizumab for July through September 2021Postpayment Service-Specific Probe Results for Drugs and Biological Services: Aflibercept (Eylea) for July through September 2021Postpayment Service-Specific Probe Results for ESRD Monthly Capitation Payments for July through September 2021Postpayment Service-Specific Probe Results for Outpatient Drugs and Biologicals: Denosumab (Prolia) for July through September 2021Postpayment Service-Specific Probe Results for Ambulance Services (Emergent): Basic Life Support for July through September 2021Postpayment Service Specific Probe Results for Ambulance Services (Emergent): Advanced Life Support for July through September 2021Cervical Fusion with Disc RemovalDocumentation Tips for Ambulance Providers: Paint the PictureNationwide Expansion: Ambulance PAPhysician/Practitioner LetterHospital Outpatient Department (OPD) Prior Authorization Exemption ProcessMedicare Record Authentication: Tips for PhysiciansUpdate: Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance TransportMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesPrior Authorization of Repetitive Scheduled Non-Emergent Ambulance TransportsAmbulance Fee Schedule and Medicare Transports CMS BookletJM Ambulance Prior Authorization Request FormPanniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related ServicesOutpatient Department Prior Authorization ExemptionJM Parts A, B and Home Health and Hospice Targeted Probe and Educate Active Medical Review ListPrior Authorization Requests for Repetitive Scheduled Non-emergent Transports DocumentationMedicare Exemption: Prior Authorization of Certain Hospital Outpatient Services VideoAmbulance Mileage

Last Updated: 04/21/2022