Medical Review

Published 04/21/2022

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: Ambulance Services A0426-A0428Targeted Probe and Educate VideoTargeted Probe and Educate Progress Update: JJ 99291-99292: Critical Care First HourTargeted Probe & Educate (TPE) Provider ContactTargeted Probe and Educate Progress Update: JJ E/M 99232-99233: Subsequent Hospital CareTargeted Probe and Educate Progress Update: JJ Ambulance A0427-A0429: Ambulance Services (Emergent)Targeted Probe and Educate Progress Update: JJ 99214/99215 Evaluation and Management: Established Patient Office VisitsWe Have Noticed a Significant Increase in 296 Auto Denials - Requested Records Not SubmittedHyperbaric Oxygen ChecklistOrders Issued Through Text MessagingCharge Denial Rate (CDR) CalculatorMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsAttestation StatementsOutpatient Therapy (OT) Exercises ChecklistErrors in Emergency Department ServicesPalmetto GBA Partnering with Providers to Get it Right the First TimeOutpatient Department Prior Authorization CalculatorOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberOutpatient Department (OPD) Prior Authorization (PA) Required DocumentationOutpatient Department (OPD) Prior Authorization (PA) Alert!Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked QuestionsOutpatient Department (OPD) Prior Authorizations (PA)Blepharoplasty and Blepharoptosis RepairPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyOutpatient Department Prior Authorization (OPD) eServices Submission GuideOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideTop 10 Medical Review Denials ModuleADR Response CalculatoresMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)Botulinum Toxin InjectionsOutpatient Department (OPD) Prior Authorization (PA)Postpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal with Insertion for October to December 2020ADRs for Outpatient Department Prior Authorization services (OPD PA) ServicesPanniculectomyPostpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal with Insertion for January through March 2021CMS MLN Fact Sheet: Medical Record Maintenance and Access RequirementsPostpayment Service-Specific Probe Results for Ambulance Service, Advanced Life Support, Non-Emergency Transport Level 1 for January through March 2021CMS 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)Targeted Probe and Educate Resumed September 1, 2021RhinoplastyAccess TPE Letters Electronically: Job AidPostpayment Service-Specific Probe Results for Ambulance Service, Advanced Life Support, Emergency Transport for July through September 2021Vein Ablation and Related Services ChecklistAmbulance Prior Authorization: Jurisdiction JAmbulance Prior Authorization eServices Form (HCPCS A0427, A0429) ModuleCMS Letter to Jurisdiction J Ambulance SuppliersPostpayment Service-Specific Probe Results for Ambulance Service, Basic Life Support, Non-Emergency Transport for July through September 2021Cervical Fusion with Disc RemovalDocumentation Tips for Ambulance Providers: Paint the PictureNationwide Expansion: Ambulance PAJJ Ambulance Prior Authorization Request FormHospital Outpatient Department (OPD) Prior Authorization Exemption ProcessMedicare Record Authentication: Tips for PhysiciansMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesPrior Authorization of Repetitive Scheduled Non-Emergent Ambulance TransportsPanniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related ServicesOutpatient Department Prior Authorization ExemptionPrior Authorization Requests for Repetitive Scheduled Non-emergent Transports DocumentationMedicare Exemption: Prior Authorization of Certain Hospital Outpatient Services VideoMedicare Documentation Signature TimelinessAmbulance MileageTargeted Probe and Educate Process ModuleMedical Review Program and Targeted Probe and Educate HandoutActive Service-Specific Postpayment Medical ReviewsPre-Payment Provider-Specific Probe Results for Denosumab (Prolia) for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Infliximab (Remicade) for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Monthly Outpatient ESRD for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Aflibercept (Eylea) for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Ambulance Services (Emergent) for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Echocardiography, Transthoracic, Real-Time with Image Documentation for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Surgical Services: Surgical Debridement for September 2021 Through March 2022Ambulance Prior Authorization Documentation Decision ToolNon-Affirmed Code Crosswalk: Prior Authorization RequestJJ Part A and Part B Targeted Probe and Educate Active Medical Review ListPostpayment Provider-Specific Probe Results for Presumptive Drug Test from September 2021 Through March 2022Post-Payment Provider-Specific Probe Results for Clinical Labs: Lipid Panel from September 2021 through March 2022eServices Status Dashboard Displays Aging ADR Alerts