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

Additional Resources

Medical Review Articles

Ambulance Services ChecklistRanibizumab ChecklistMedical Review of Non-Emergency BLS TransportPortable X-Ray ChecklistChest X-Ray ChecklistDrug Screening ChecklistDiagnostic Radiology: Chest X-Ray ServicesMedical Review of Emergency ALS TransportsBone Density Study ChecklistTargeted Probe and Educate VideoTargeted Probe & Educate (TPE) Provider ContactRituximab Check ListPalmetto GBA Partnering with Providers to Get it Right the First TimeMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsOverview of Prepayment and Postpayment Claim ReviewAdditional Documentation Request (ADR) Separator SheetComplying with Medicare Signature RequirementsMedical Review Program and Targeted Probe and Educate HandoutBone Mass Measurements (BMM) ServicesMedical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicMedical Review: Additional Documentation Requests (ADRs)Always Supply Medical Records When Requested by the Benefit Integrity UnitRailroad Medicare Implemented Automated Calls to Assist Providers with ADR ResponsesReceiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewMACs Resume Medical Review on a Postpayment BasisChiropractic Claims Submitted with Both the 'AT' and 'GA' Modifier to RejectRailroad Medicare and the Targeted Probe and Educate ProcessRailroad Medicare's Resumption of Medical Review on a Postpayment BasisRailroad Medicare's Resumption of Medical Review on a Postpayment BasisTargeted Probe and Educate: September 2021 to September 2022 Planned ReviewsMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesDenosumab ChecklistAmbulance Reason Code CrosswalkMedical Review Prepayment Reviews: October 2021-September 2022 Planned ReviewsActive Medical Reviews: October 2021 Through September 2022Active Medical Reviews: October 2021 Through September 2022Targeted Probe and Educate Process ModuleEntries in Medical Records: Amendments, Corrections and Addenda

Last Updated: 08/31/2021