100-08 Medicare Program Integrity Manual: Chapter 7 - MR Reports

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Medicare Program Integrity Manual
Chapter 7 - MR Reports
Table of Contents
(Rev. 10365, 10-02-20)
Transmittals for Chapter 7
7.1 – Annual Improper Payment Reduction Strategy (IPRS)
7.1.1 – General Overview
7.1.2 – IPRS Required Format
7.1.2.1 - Cover Page
7.1.2.2 - Overview/Executive Summary
7.1.2.3 - Data Analysis and Information Gathering Plan
7.1.2.4 - Prioritized Problem List
7.1.2.4.1 - Carried Over Prioritized Problems
7.1.2.5 - MR Activities and Improper Payment Interventions Planning
7.1.2.5.1 – Contractor Suggestions
7.1.2.6 - Program Management
7.1.2.6.1 - Budget and Workload Management
7.1.2.6.1.1 – Workload Reporting Tables
7.1.2.6.2 - Staffing and Workload Management
7.1.2.7- Quality Assurance (QA) Plan
7.1.2.7.1 –QA for Data Analysis and Information Gathering
7.1.2.7.2 - QA for Development of the Prioritized Problem List
7.1.2.7.3 - QA for Program Management
7.1.3 – IPRS Submission
7.1.4 – IPRS Revision
7.2 - Medical Review Definitions
7.2.1 - Background
7.2.2 - Definitions
7.2.2.1- Automated Medical Review
7.2.2.2 – Non-Medical Record Review
7.2.2.3 - Demand Bill Claims Review
7.2.2.4 - Medical Review Reopening
7.2.2.5 - Prepay Provider Specific Medical Record Review
7.2.2.6 - Prepay Service Specific Medical Record Review
7.2.2.7 - Prepay Provider Specific Probe Medical Record Review
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7.2.2.8 - Prepay Service Specific Probe Medical Record Review
7.2.2.9 - Advanced Determination of Medicare Coverage (ADMC)
7.2.2.10 - Postpay Provider Specific Probe Medical Record Review
7.2.2.11 - Postpay Service Specific Probe Medical Record Review
7.2.2.12 - Postpay Provider Specific Medical Record Review
7.2.2.13 - Postpay Service Specific Medical Record Review
7.2.2.14 - Data Analysis
7.2.2.15 - Medical Review Edit Development
7.2.2.16 - Externally Directed Reviews
7.2.2.17 - Provider Compliance Group Directed Reviews
7.2.2.18 - One on One Education
7.2.3 - Coding
7.2.4 - Monthly Reporting of Medical Review Savings
7.3 – The Strategy Analysis Report (SAR)
7.3.1 - General Overview
7.3.2 - SAR Required Format
7.3.2.1 - Cover Page
7.3.2.2 - Overview/Executive Summary
7.3.2.3 - Prioritized Problem List
7.3.2.4 - MR Activities and Improper Payment Interventions Planning
7.3.2.5 - Program Management
7.3.2.5.1 - Budget and Workload Management
7.3.2.5.1.1. - Workload Reporting Tables
7.3.2.5.2 - Staffing and Workload Management
7.3.3 - Quality Assurance (QA) Plan
7.3.4 – SAR Submission
7.3.5 – SAR Revision
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7.1 - Annual Improper Payment Reduction Strategy (IPRS)
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
7.1.1 - General Overview
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The annual Improper Payment Reduction Strategy (IPRS) is a problem-focused,
outcome-based operational plan developed by the Medicare Administrative Contractor
(MAC) that identifies risks to the Medicare Trust Fund and describes the improper
payment interventions to be implemented to ensure proper payments and address the
risks. The IPRS addresses both provider and service-specific vulnerabilities and includes
a prioritization of the problems based on data analysis findings and the availability of
resources.
Specifically, the IPRS details:
• 	Identified medical review (MR) prioritized problems
• 	Data analysis for each prioritized problem
• 	All MR activities, provider outreach & education (POE), and other improper
payment interventions focused on the prioritized problems
• 	Measureable and achievable improvement goals for each prioritized problem
• 	Evaluation methodology for the planned goals and improper payment
interventions
• 	Quality assurance activities
• 	Workload and staffing detail
• 	Program management information
7.1.2 - IPRS Required Format
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
All elements listed below shall be addressed by the MAC in the IPRS. Each of these
requirements is described in detail in the following sections:
• 	Cover Page
• 	Overview/Executive Summary
• 	Data Analysis and Information Gathering Plan
• 	Prioritized Problem List
• 	MR Activities and Improper Payment Interventions Planning
• 	Program Management
• 	Quality Assurance Plan
7.1.2.1 - Cover Page
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The cover page shall include the following information:
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• 	MAC name and address
• 	MAC contract number
• 	States in jurisdiction
• 	Period of performance (an explanation shall be included if the IPRS is reporting
on a period of performance less than 12 months)
• 	Report coordinator contact information (name, telephone number and e-mail
address)
• 	IPRS due date and submission date
7.1.2.2 - Overview/Executive Summary
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall provide a high level summary of their planned MR activities, improper
payment interventions, and quality assurance activities for their upcoming period of
performance.
7.1.2.3 - Data Analysis and Information Gathering Plan
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall target their efforts on those services, items, and providers/suppliers in their
jurisdiction that pose the greatest financial risk to the Medicare Trust Fund and that represent
the best investment of resources to reduce the national improper payment rate (IPR).
The first step in creating or updating an IPRS is to establish a priority-setting process to
assure MR activities and other interventions are focused on areas with the greatest potential
for improper payments. The MACs shall analyze and gather data from a variety of sources
for this purpose. The MACs’ Comprehensive Error Rate Testing (CERT) findings shall
be used as a primary source of data. However, CERT findings are only one indication of
where to focus and shall not be relied upon as the single source of data information. The
MAC shall consult a variety of resources. Examples of other appropriate resources
include, but are not limited to:
• 	Recovery Auditor-identified problem
• 	Comparative billing reports (CBRs)
• 	Office of Inspector General (OIG) or Government Accountability Office (GAO)
reports
• 	MAC data analysis on a specific benefit, diagnostic/procedure code, or place of
service. This analysis shall include an identification of the specific cause of
improper payments
• 	Evaluation of utilization or probes
The MAC shall provide detailed information of the data analysis conducted for purposes
of developing the IPRS. The data analysis plan shall list the data resources used in
developing the prioritized problem list. If a prioritized problem is carried over from a
previous IPRS or Strategy Analysis Report (SAR) the MAC shall provide information
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regarding the current, updated data analysis conducted to ensure that the prioritization of
the problem is accurate and current. If a former prioritized problem is not carried over
from a previous IPRS or SAR, an explanation and data shall also be provided.
7.1.2.4 - Prioritized Problem List
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall develop a prioritized problem list after data analysis has been completed.
The MAC shall list five to ten prioritized problems, for each appropriate claim type
(Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS), Part A, Part
B, and Home Health and Hospice (HHH)), selected for inclusion in the IPRS.
The MAC shall describe the method, criteria, and data analysis used to prioritize the
problem list. The MAC shall consider their resources and other operational areas of the
MAC with similar goals when developing the prioritized problem list.
The prioritized problem list shall include the identified payment errors/vulnerabilities that
can be addressed through MR activities, POE, and other improper payment interventions.
The MR problems for the current contract year, as well as problems that are carried over
from the previous IPRS or SAR, shall be included. Any prioritized problems carried over
from a previous IPRS or SAR shall include an explanation. The MAC shall also include a
rationale if top errors identified by CERT are not included in the prioritized problem list.
Top errors would be the top service/claim types by projected improper payments within
the MAC’s jurisdiction and nationally.
The following requirements shall be included for each specific prioritized problem:
• 	Whether the prioritized problem is a new or a carry-over problem.
• 	Data source/analysis that led to the identification of the problem. The IPRS
shall identify the source of data that led to the identification of the problem for
inclusion in the IPRS.
• 	MAC-specific improper payment rate as measured by the CERT program
and/or the MAC. This information shall demonstrate how this problem
contributes to the MAC and national improper payment rates. The MAC shall
specify whether the improper payment rate was measured by the CERT program
or the MAC.
• 	Cause(s) of the problem. The IPRS shall identify the specific cause of the
error/vulnerability resulting in improper payments. Such causes may include, but
are not limited to, insufficient clinical documentation, incorrect coding,
unnecessary utilization, inadequate provider understanding of relevant CMS rules,
lack of medical necessity, or the rendering of services in the incorrect clinical
setting.
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• 	Baseline measurement to be used for the purpose of assessing improvement.
The IPRS shall identify the baseline measurement that will be used for the
purpose of assessing improvement through time. This section shall also describe
the process for calculating the starting/baseline problem measurement (e.g., IPR,
claims denial rate, charges denial rate, provider error rate). An assessment of
progress towards accomplishment of the improvement goals cannot be made
unless the starting point/baseline problem measurement is known. For example,
an improvement goal to reduce the problem measurement or to improve provider
compliance with coverage requirements by a specific percentage without the
baseline or starting problem measurement does not enable measurement of
progress towards the improvement goal.
• 	Achievable and measureable improvement goals. The IPRS shall include
concrete improvement goals for each prioritized problem that are data-driven,
achievable, and measurable. The establishment of improvement goals will require
the MAC to use information from the MAC MR, data analysis, POE, and other
departments, as appropriate. CMS does not mandate the MAC to use any specific
improvement goal; however, selected improvement goals and MR activities and
improper payment interventions shall ultimately contribute to lowering the overall
improper payment rate and/or to an improvement in provider billing behavior.
The outcome shall be the reduction of the starting/baseline problem measurement
as listed in the specific improvement goal (e.g. improvement of provider
billing/provider error rate; number of providers removed from review due to
decrease in their error rate, reduction of error rate etc.). Specifically, this section
shall include:
o 	The timeframe to achieve the improvement goal.
o 	An explanation of progress or lack of progress towards accomplishment of
the improvement goal (when the improvement goal is carried over from the
previous IPRS or SAR).
o 	Parameters or thresholds for removing a provider/supplier from MR
activities or other interventions as it relates to the improvement goal.
o 	Evaluation methods that test the effectiveness and efficiency of MR
activities and other improper payment reduction interventions.
7.1.2.4.1 – Carried-Over Prioritized Problems
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
In addition to the requirements listed above, the MAC shall address the following
elements for problems that are carried over from previous contract year’s IPRS or SAR to
the current contract year’s IPRS. These sections shall include problem-specific discrete
figures and measurements:
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• 	The effectiveness or ineffectiveness of the MR, POE, and other improper
payment interventions in reducing the baseline problem measurements. The
MAC shall document the progress made towards achieving the goal, or an
explanation of why the goal was partially met or not met within the specified
timeframe. If there is lack of progress towards accomplishment of an
improvement goal, the MAC shall clearly document the obstacles contributing to
the lack of progress towards accomplishment of an improvement goal. The MAC
shall also offer rationale for either not taking the next steps in progressive
corrective action or for continuing current interventions. A continuous lack of
progress towards goal completion and failure to provide a justification for the lack
of progress will be considered unacceptable and require revisions to the IPRS.
• 	Whether modification to the plan is required. A modified plan, if appropriate,
shall be developed by the MAC to remedy the obstacles that inhibited progress
towards accomplishment of the improvement goals. This section shall describe
how the MAC is revising or modifying the goals and/or the MR, POE, and other
improper payment interventions, as appropriate.
No previous prioritized problems may be omitted from the current IPRS without an
explanation. CMS must be able to track progress on all prioritized problems and their
goals from a previous IPRS. When previous prioritized problems improve or meet their
goals, or when priorities shift to other problem areas, the MAC may inactivate the
previous prioritized problem or set new improvement goals for that problem.
7.1.2.5 - MR Activities and Improper Payment Interventions Planning
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
For each prioritized problem, the MAC shall develop a comprehensive plan of MR
activities and other improper payment interventions using the Progressive Corrective
Action (PCA) process. The MAC shall develop multiple tools to effectively address
identified problems. The scope and severity of the identified problems shall determine the
MR activities and improper payment interventions needed to successfully address the
problems.
The MR activities and improper payment interventions shall be tailored to the nature of
the problem. Existing interventions that have proven effective in reducing improper
payments shall be used as one basis for the implementing of MR activities and other
improper payment interventions. The effectiveness of existing MR activities and other
improper payment interventions shall be explained in discrete figures and/or improper
payment rates.
The MAC shall include an estimated date of implementation for each planned MR
activity and improper payment intervention.
The MR activities and improper payment interventions may include, but are not limited
to:
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• 	MR Activities
• 	Provider or service-specific probes
• 	Targeted medical reviews (TMRs)
• 	Notification letters
• 	POE priority referrals
• 	Automated denials based on local coverage determinations (LCDs)
• 	Edit modifications
• 	Post-payment and statically valid random sampling (SVRS)
extrapolation
• 	Development or revisions of LCDs
• 	Probe review education
• 	POE activities
• 	Recalcitrant provider process
The MAC shall describe the process for provider selection for MR activities and other
improper payment interventions. For example, the MAC may describe review criteria in
the following manner: “Providers whose denied claims represent over x percent of the
dollar amount reviewed will be placed on a prepay review or providers who have a
provider error rate > x percent will be placed on an x percent prepay review.”
If initial MR activities and improper payment interventions are insufficient to improve
the provider’s billing behavior, a priority referral to POE for potential intervention may
be necessary. A POE priority referral indicates to the POE department that this is a
problem which MR has determined will likely require further educational intervention.
Through communication with POE, it is determined that MR activities, improper
payment interventions and POE educational efforts have not effectively resolved the
problem, a referral to the Unified Program Integrity Contractors (UPIC), Recovery
Auditor or the recalcitrant process may be indicated.
If an improper payment intervention is to refer the provider to another entity, i.e.,
Recovery Auditor, UPIC, or Quality Improvement Organization (QIO), the MAC shall
have backup MR activities or improper payment interventions if the referral is not
accepted by the other entity.
The MR department shall employ an effective follow-up process that ensures appropriate
resolution of the issue. If provider billing aberrances continue, the MAC shall use
information obtained via consultation with other areas of the MAC which shall include
the POE department to develop a revised comprehensive plan of MR activities and other
improper payment interventions using the PCA process. This plan may involve increases
in MR prepay review or conducting Statistical Sampling for Overpayment Estimation
(SSOE). As issues are successfully resolved, the MAC shall continue to address other
program errors/vulnerabilities identified on the prioritized problem list.
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The MAC MR department shall have a system to track all referrals to POE, medical
review activities, and improper payment interventions used to address identified
problems. The MAC MR shall work with POE to develop an effective tracking system
for referred problems. The Contractor shall track all contacts made by their MR unit with
providers, UPICs, and Recovery Auditors during the course of medical review.
7.1.2.5.1 - Contractor Suggestions
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
Contractors shall report suggestions on how CMS can help reduce the national improper
payment rate (e.g., may include national efforts, policy changes, or other broad
strategies).
7.1.2.6 - Program Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
Program management encompasses managerial responsibilities inherent in managing the
MR program, including: development, modification, and reporting of strategies and
quality assurance activities; planning, monitoring, and adjusting workload performance;
budget-related monitoring and reporting; and implementation of CMS MR
changes/instructions.
7.1.2.6.1 - Budget and Workload Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The IPRS shall include a section that describes the process used to monitor budget and
workload for the MR activities definitions. The process shall ensure that spending is
consistent with the allocated budget and include procedures to revise or amend the plan
when spending is over or under the budget allocation. The MAC shall have a table in the
IPRS identifying the MR workload for the current period of performance.
The MAC shall assess the cost effectiveness of each MR activity and appropriateness of
each MR activity. The MAC shall determine if the resources required for the planned
MR activity can contribute to achieving the reduction of the improper payment error rate.
In addition, the IPRS shall describe how workload for each MR activity is accurately and
consistently reported. The workload reporting process shall also assure the proper
allocation of employee hours required for each MR activity.
7.1.2.6.1.1 – Workload Reporting Tables
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
The following tables shall be included in the IPRS:
Medical Review Program Workload A/B MAC and HHH MAC
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Statement
of Work
(SOW)
MR Activity
Part A
Projected
Workload
for this
Period of
Performance
Part B
Projected
Workload
for this
Period of
Performance
Home Health
Projected
Workload
for this
Period of
Performance
Hospice
Projected
Workload
for this
Period of
Performance
C.5.12.1.6 	Defending MR
Decisions at ALJ
Hearings
C.5.12.2.1 	Automated
Medical Review
C.5.12.2.2 	Non-Medical
Record Review
C.5.12.2.3 	Demand Bill
Claims Review
C.5.12.2.4 	Medical Record
Review
Reopening
C.5.12.2.5 	Prepay Provider
Specific Medical
Record Review
C.5.12.2.6 	Prepay Service
Specific Medical
Record Review
C.5.12.2.7 	Prepay Probe
Provider Specific
Medical Record
Review
C.5.12.2.8 	Prepay Probe
Service Specific
Medical Record
Review
C.5.12.2.10 	Postpay Probe
Provider Specific
Medical Record
Review
C.5.12.2.11 	Postpay Probe
Service Specific
Medical Record
Review
C.5.12.2.12 	Postpay Provider
Specific Medical
Record Review
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Statement
of Work
(SOW)
MR Activity
Part A
Projected
Workload
for this
Period of
Performance
Part B
Projected
Workload
for this
Period of
Performance
Home Health
Projected
Workload
for this
Period of
Performance
Hospice
Projected
Workload
for this
Period of
Performance
C.5.12.2.13 	Postpay Service
Specific Medical
Record Review
C.5.12.2.17 	Externally
Directed
Reviews
C.5.12.2.18 	Provider
compliance
Group Directed
Reviews
C.5.12.2.20 	One on One
Education
Medical Review Program Workload DME MAC
SOW 	MR Activity
Projected workload
for this Period of
Performance
4.7.1 	Automated Medical Review
4.7.2 	Non-Medical Record Review
4.7.3 	Demand Bill Claims Review
4.7.4 	Medical Record Review Reopening
4.7.5 	Prepay Provider Specific Medical Record Review
4.7.6 	Prepay Service Specific Medical Record Review
4.7.7 	Prepay Probe Provider Specific Medical Record
Review
4.7.8 	Prepay Probe Service Specific Medical Record
Review
4.7.10 	Postpay Probe Provider Specific Medical Record
Review
4.7.11 	Postpay Probe Service Specific Medical Record
Review
4.7.12 	Postpay Provider Specific Medical Record Review
4.7.13 	Postpay Service Specific Medical Record Review
4.7.17 	Externally Directed Reviews
4.7.18 	Provider Compliance Group Directed Reviews
4.7.22 	One on One Education
4.12 	Defending MR decisions at ALJ Hearings
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7.1.2.6.2 - Staffing and Workload Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MACs shall list the number, job titles, and qualifications/credentials of all full-time-
equivalent (FTE) employees. If resources allow, an MR Nurse may be shared with
another functional area, such as claims processing, so long as only the percentage of the
nurses time spent on MR activities is identified in the strategy and accounted for in the
appropriate functional area. For example, if MR agrees to share 0.5 of an FTE with
claims processing to assist with the pricing of Not Otherwise Coded claims, this 0.5 FTE
shall be accounted for in claims processing and not in MR.
7.1.2.7 - Quality Assurance (QA) Plan
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
In each element of the IPRS, the MAC shall incorporate quality assurance (QA)
activities. The QA activities ensure that each element is performed consistently and
accurately throughout the MAC’s MR program. The MAC shall have in place
continuous quality improvement procedures. Quality improvement procedures use
information yielded from quality assurance methods and allow the MAC to analyze the
outcomes from their program and to continually improve the effectiveness of their
processes.
The QA process shall include effective consultations between MR, POE, and other
components, as appropriate, to ensure that duplicate efforts are not being undertaken. The
QA process shall inform the MAC if claims subject to MR activity are consistently
overturned on appeal. An effective QA process shall include regular meetings with other
operational areas, including data analysis, policy development, POE, and appeals.
Because the MAC is tasked with evaluating their MR program activities, it is necessary
to establish QA activities that include thresholds and time limits for the MAC to assess
their MR operations that ultimately improve the IPR. Examples include, but are not
limited to:
• 	Data analysis
• 	Educational interventions
• 	Inter-Rater Reliability (IRR) for MR licensed health care professionals and
certified coders participating in medical review
o 	Define acceptable IRR rates and actions taken for not meeting those
acceptable rates
• 	Accuracy of medical review decisions
o 	Define acceptable accuracy rates and actions taken for not meeting those
acceptable rates
• 	Overturn rate on appeals
• 	Cost of review
• 	Edit effectiveness
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7.1.2.7.1 - QA for Data Analysis and Information Gathering
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall develop a QA process for data analysis and information gathering that
frequently reviews the data and how the information is used.
The MAC shall:
• 	Establish an internal process for routinely reviewing data results
• 	Document the job titles, qualifications and contract operational areas represented
by those who routinely review the data results
• 	Describe the log tracking system(s) utilized for data analysis and how this
information was developed by the MAC
• 	Describe how decisions are made as a result of the data analysis meetings.
7.1.2.7.2 - QA for Development of the Prioritized Problem List
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall list the data and the metrics used to determine and verify each identified
prioritized problem. That is, each identified prioritized problem shall have an
explanation of current data and other information used to support the decisions to include
the problem and assign its priority. The QA process shall ensure that MR activities and
improper payment interventions are not dedicated to problems that are consistently
overturned on appeal, based on outdated data analysis, or the focus of other operational
areas of the MAC with similar goals.
The QA shall be performed for each intervention that checks for effectiveness and
progress towards the specified goal. The QA component shall include a projected goal, a
timeline to achieve the goal, and an element to assess effectiveness of the intervention
and progress towards the stated goal. The QA component shall include a determination
of whether the problem has been resolved or partially met, or whether a more progressive
course of action is required. The MAC shall evaluate the effectiveness of edits and the
priority status of the problem. An effective QA process shall also include periodic
meetings with other operational areas, such as POE.
7.1.2.7.3 - QA for Program Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall describe the processes employed to assure accuracy and consistency in
the reporting of spending, workload, and staffing levels. The MAC shall address how to
maintain accuracy in medical review decision-making and IRR assessments and shall
report the results of the IRR for the MR licensed health care professionals and certified
coders participating in the medical review process. Each IPRS, SAR shall contain the
IRR scores for the period of performance covered by that reporting period.
7.1.3 - IPRS Submission
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(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall submit an IPRS as directed by the SOW and Contracting Officer’s
Representative (COR). The current IPRS shall be updated or revised as required by the
COR after review by the Business Function Leads (BFLs) (MR, CERT and POE) and the
Regional Office (RO) Technical Monitor (TM) MR staff.
7.1.4 - IPRS Revision
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall notify their COR, RO TM and the MR BFL when their IPRS requires a
revision/update of the final approved IPRS. Any revisions/updates shall be described in
the medical review section of the current monthly status report. The IPRS revision shall
be included in the next strategy deliverable (either the IPRS or SAR).
7.2 - Medical Review Activity Definitions
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
7.2.1 - Background
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
This section provides requirements and instructions for Part A, Part B, and Durable
Medical Equipment (DME) MACs, fiscal intermediaries (FIs), and carriers.
The reporting requirements for Medical Review (MR) activities performed by the
Contractor were formerly captured in the Program Integrity Management Reporting
(PIMR) system. Effective 7/1/2012, the PIMR system was retired, requiring the revision
to this chapter of the Program Integrity Manual.
The new process for the oversight of Medical Review activities administered by the
Contractor will improve the management of medical review cost, savings, and workload.
The manual Medical Review Savings reporting process will replace the Program Integrity
Manual Review system.
The Medical Review, savings, and workload data shall be collected through the use of a
manual report until such a time that it is decided that an automated reporting system is
required and developed to meet the business needs of The CMS Office of Financial
Management, Provider Compliance Group, Division of Medical Review and Education.
The CMS will obtain Medical Review Savings data through manual reporting by
Contractor staff. Those reports will be due monthly, on the20th day of the month.
7.2.2 – Definitions
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(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
The reporting process will require data that can be classified under three different
categories of activity measures: Workload, Cost, and Savings. The Medical Review
definitions shall apply to all Medical Review activities and shall not be deviated from or
interpreted differently than stated below. The consistency in the application of these
definitions will provide validity to the data reported that is required to assess the
effectiveness of the CMS Medical Review and Education Program being administered by
the Contractor(s)
MEDICAL REVIEW
The review of claims and associated medical documentation that occurs when review
staff:
1. 	Make a coverage decision (benefit category, statutory exclusion, or reasonable
and necessary) and a coding decision to determine the appropriate payment for
claims, or
2. 	Investigate complaints to determine whether a corrective action was effective
(e.g., an MR activity such as provider notification letter), or identify situations
that require prepayment edits or the development of a local coverage
determination (LCD).
The medical review process requires the application of clinical judgment either as part of
a review, in writing policies, or in the development of guidelines and processing
instructions. For local medical review edits, input must be from the Contractor Medical
Review clinicians/staff. For national edits, input from the Contractor medical/clinical
staff is not necessary. The medical review can be performed either before or after the
claim has been paid. Generally, a line cannot result in medical review workload or
savings if it is not referred to medical review. A line that potentially involves both
medical review and claims processing work should suspend to a claims processing
reviewer, and that reviewer should refer the line to medical review only if the claims
processing reviewer cannot make a decision based on guidelines available to that
reviewer.
Do NOT consider the review as medical review if it requires:
1. 	Pricing Only, or
2. 	Coding Only, or
3. 	Pricing and Coding only.
Consider the review as medical review if:
1. 	Pricing is based on medical record review determination. or
2. 	Coding is based on medical record review determination, or
Complete printed PDF page 15
3. 	Coding and Pricing are based on medical record review determination.
If an automated claims processing edit has already made a decision to pay, and the claim
only suspends for pricing, consider the review automated claims processing and do not
count it for medical review workload or costs.
7.2.2.1 - Automated Medical Review
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
A medical review is considered automated when a payment decision is made at the
system level, using available electronic information, with no manual intervention. It
must be based on guidelines for which the contractor’s Medical Review area has
developed some or all of the logic for review of specific billing and coverage criteria
based on vulnerabilities identified by the Contractor’s Medical Review area. This
process is done completely through the Medical Review Contractors' technology
developed in response to medical review data analysis.
7.2.2.2 - Non-Medical Record Review
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Non-medical record reviews uses manual intervention, but only to the extent a reviewer
can make a determination based on information on a claim. It does not require clinical
judgment in review of medical record documentation. Contractors shall only perform a
non-medical record review for denials of related claims and/or no receipt of ADR
documentation where such denials cannot be automated.
7.2.2.3 - Demand Bill Claims Review
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
Demand bills are submitted at the beneficiary’s/representative’s request because the
beneficiary disputes the provider’s opinion that the bill will not be paid by Medicare and
requests the bill be submitted for a payment determination. The demand bill is identified
by the presence of a condition code 20. There must be a written request from the
beneficiary to submit the bill, unless the beneficiary is deceased or incapable of signing.
In this case, the beneficiary’s guardian, relative or other authorized representative may
make the request. This includes SNF and HHA demand bills as well as other demand
bills (outpatient) and Third Party Liability Medical Reviews.
7.2.2.4 - Medical Review Reopening
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
Complete printed PDF page 16
A MR reopening is a remedial action taken to review and change a final determination or
decision that resulted in either an overpayment or an underpayment, even though the
determination for decision was correct based on the evidence in the record. It is separate
and distinct from the appeals process. The Contractor may choose to reopen a claim for
late documentation. The MR department shall conduct a reopening of claims sent by the
appeals department which meet the criteria in IOM Pub. 100-04, Section 10.3. (1) A
provider failed to timely submit documentation through an Additional Documentation
Request (ADR) (2) Claim was denied because the requested documentation was not
received timely (3) the requested documentation is received after the 45 day period with
or without a request for redetermination or reopening AND (4) The request is filed
within 120 days of the receipt of the initial determination. Do not count more than one
reopening per claim.
7.2.2.5 - Prepay Provider Specific Medical Record Review
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. This includes requests for, collection and
evaluation of medical records or any other documentation. The review is as a result of
vulnerabilities determined by data analysis and identified in the Medical Review strategy.
If the requested documentation is not received, the review is not considered medical
record review. The failure of the provider to submit documentation shall result in a
denial. Contractors shall use Group Code: CO - Contractual Obligation and Claim
Adjustment Reason Code (CARC) 50 - these are non-covered services because this is not
deemed a “medical necessity” by the payer and Remittance Advice Remark Code
(RARC) M127 - Missing patient medical record for this service. For the purpose of
calculating and reporting MR workload, cost and savings, contractors shall count these
denials as automated reviews or non-medical record reviews depending on the method of
development.
7.2.2.6 - Prepay Service Specific Medical Record Review
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Service specific prepay medical review of claims
requires that a medical review determination be made before claim payment directed at a
certain service. It includes requests for, collection and evaluation of medical records or
any other documentation. The review is as a result of vulnerabilities determined by data
analysis and identified in the Medical Review strategy. The failure of the provider to
submit documentation shall result in a denial. Contractors shall use Group Code: CO -
Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 - these are non-
covered services because this is not deemed a “medical necessity” by the payer and
Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for
this service. For the purpose of calculating and reporting MR workload, cost and savings,
contractors shall count these denials as automated review or non-medical record review
depending on whether the denial is automated or requires manual intervention.
Complete printed PDF page 17
7.2.2.7 - Prepay Provider Specific Probe Medical Record Review
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Prepay probe medical record reviews are done to
verify that the program vulnerability identified through data analysis actually exists and
will require education and possible targeted medical record review. In the case of a
possible provider specific problem, contractors should generally use a sample of 20 -40
claims submitted by that individual provider.
The Contractor shall validate data analysis findings by conducting probe reviews and
implementing the necessary PCAs in accordance with IOM Pub.100-08 Chapter 3. Once
a problem has been verified, the Contractor shall implement the necessary PCA. This
includes providing the initial notification informing the provider of the results of the
probe review, and collaborating with Provider Outreach and Education (POE) to share
potential educational needs, and making referrals to POE, UPICs, RACs, or others as
appropriate.
7.2.2.8 - Prepay Service Specific Probe Medical Record Review
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Prepay service specific probe medical record
reviews are done to verify that the program vulnerability identified through data analysis
actually exists and will require education and possible targeted medical review. For
Prepay review in the case of a possible systemic problem, the contractor shall include a
random or stratified sample of generally 100 claims submitted from across all providers
or suppliers that bill the particular item or service in question.
The Contractor shall validate data analysis findings by conducting probe reviews and
implementing the necessary PCAs in accordance with IOM Pub.100-08 Chapter 3. Once
a problem has been verified, the Contractor shall implement the necessary PCA. This
includes providing the initial notification of the results of the probe review, and
collaborating with Provider Outreach and Education (POE) to share potential educational
needs, and making referrals to POE, UPICs, RACs or others as appropriate.
7.2.2.9 - Advance Determination Medicare Coverage (ADMC)
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
At the request of a supplier or beneficiary, the DME MAC may determine in advance of
delivery of an item whether payment for that item is medically necessary. The request
must contain adequate information from the patient’s medical record to identify the
Complete printed PDF page 18
patient for whom the item is intended, the intended use of the item, and the medical
condition of the patient that necessitates the use of the item.
7.2.2.10 - Postpay Provider Specific Probe Medical Record Review
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Postpay provider specific probe medical record
reviews are done to verify that the program vulnerabilities identified through data
analysis actually exist and will require education and/or further medical review. For
postpay review of an individual provider in the case of a possible provider specific
problem, contractors shall include in the probe sample a random or stratified sample of
generally 20 -40 claims from that provider with dates of service from the period under
review.
The Contractor shall validate data analysis findings by conducting probe reviews and
implementing the necessary PCAs in accordance with, IOM Pub. 100-08 Chapter 3. Once
a problem has been verified, the Contractor shall implement the necessary PCA. This
includes providing the initial notification informing the provider of the results of the
probe review, and collaborating with Provider Outreach and Education (POE) to share
potential educational needs, and making referrals to POE, UPICs, RACs or others as
appropriate.
7.2.2.11 - Postpay Service Specific Probe Medical Record Review
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Postpay service specific probe medical record
reviews are done to verify that the program vulnerabilities identified through data
analysis actually exist and will require education and/or further medical review. For
Postpay review in the case of a possible service/systemic problem, the contractor should
generally include a random or stratified sample of 100 claims with dates of service from
the period under review from across all providers or suppliers that bill the particular item
or service in question.
The Contractor shall validate data analysis findings by conducting probe reviews and
implementing the necessary PCAs in accordance with, IOM Pub. 100-08 Chapter 3. Once
a problem has been verified, the Contractor shall implement the necessary PCA. This
includes providing the initial notification of the results of the probe review, and
collaborating with Provider Outreach and Education (POE) to share potential educational
needs, and making referrals to POE, UPICs, RACs or others as appropriate.
7.2.2.12 - Postpay Provider Specific Medical Record Review
(Rev. 721, Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Complete printed PDF page 19
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Provider specific postpay medical record review
of claims requires that a benefit category review, statutory exclusion review, and/or
reasonable and necessary review be made after claim payment directed at an individual
provider. This includes requests for, collection and evaluation of medical records or any
other documentation. The review is as a result of vulnerabilities determined by data
analysis and identified in the Medical Review strategy. The failure of the provider to
submit documentation shall result in a denial. Contractors shall use Group Code: CO -
Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 - these are non-
covered services because this is not deemed a “medical necessity” by the payer and
Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for
this service. For the purpose of calculating and reporting MR workload, cost and
savings, this is postpay medical record review and is not to be counted as a probe review.
7.2.2.13 - Postpay Service Specific Medical Record Review
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Medical record review requires a licensed medical professional to use clinical review
judgment to evaluate medical records. Service specific postpay medical record review of
claims requires that a benefit category review, statutory exclusion review, and/or
reasonable and necessary review be made after claim payment directed at a certain
service. This includes requests for, collection and evaluation of medical records or any
other documentation. The review is as a result of vulnerabilities determined by data
analysis and identified in the Medical Review strategy. If the requested documentation is
not received, it is not considered a medical record review. The failure of the provider to
submit documentation shall result in a denial. Contractors shall use Group Code: CO -
Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 - these are non-
covered services because this is not deemed a “medical necessity” by the payer and
Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for
this service. For the purpose of calculating and reporting MR workload, cost and
savings, this is postpay medical record review and is not to be counted as a probe review.
7.2.2.14 - Data Analysis
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
Used to identify and verify potential errors to produce the greatest protection for the
Medicare program. Data analysis is an essential first step in determining whether
patterns of claims submission and payment indicate potential problems. It includes
simple identification of aberrancies in billing patterns within a homogeneous group, or
much more sophisticated detection of patterns within claims or groups of claims that
might suggest improper billing or payment. Data analysis is undertaken as a part of
general surveillance and review of submitted claims, conducted in response to
information about specific problems stemming from complaints, provider or beneficiary
Complete printed PDF page 20
input, fraud alerts, reports from CMS, other ACs, MACs, or independent government and
nongovernmental agencies.
Background 	The Contractor uses CERT findings, internal and external data sources,
review of claims, and information from other operational areas to
identify patterns of erroneous billing submissions and areas of over
utilization to target provider-specific review.
7.2.2.15 - Medical Review Edit Development
(Rev. 642, Issued: 02-22-16, Effective: 02-16-16, Implementation: 02-16-16)
Medical Review edit development includes all activities necessary to create and set up a
computerized logic test developed with the assistance of health professionals that
compares the data elements on a Medicare claim for the purposes of: (1) making a local
coverage or coding determination; or (2) suspending a claim so such determinations can
be made by appropriate Medical Review personnel prior to or after payment of the claim.
7.2.2.16 - Externally Directed Reviews
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Medical reviews directed by or directly supporting the OIG, law enforcement, UPICs, or
court orders, when funded by CMS.
7.2.2.17 - Provider Compliance Group Directed Reviews
(Rev. 642, Issued: 02-22-16, Effective: 02-16-16, Implementation: 02-16-16)
Includes only those Medical reviews and special studies directed by or directly
supporting action requested by the Provider Compliance Group (PCG). Contractors shall
only count workload under this category as directed or requested by PCG and their
COTR.
7.2.2.18 - One on One Education
(Rev. 835; Issued: 10-12-18; Effective: 11-13-18; Implementation: 11-13-18)
This applies to MAC and SMRC.
One-on-one education places emphasis on reducing the paid claims error rate by
notifying, either in writing or orally, the individual billing entities (i.e., providers,
suppliers, or ordering clinician) of review findings identified on specific claims or a
group of claims reviewed on probe or targeted medical review by the MAC, RAC, or
SMRC, or based on billing patterns identified by data analysis (e.g., CBRs, OIG reports,
PEPPER/FATHOM reports, RAC findings, CERT improper payment findings).
• One-on-one education does not include:
• 	Educational articles impacting nationwide issues
• 	Responses to inquiries on claims that were not medically reviewed
Complete printed PDF page 21
• 	General training sessions
• 	POE education activities
• 	Speaking at society meetings
• 	Writing articles in society newsletters regarding new or significantly revised
LCDs.
Note: For the purpose of Targeted Probe and Educate (TPE) and TPE specific reporting,
letters shall not be considered or reported as one on one education. Please see PIM
chapter 3, section 3.2.5 for details regarding the definition of TPE one-on-one education.
7.2.3 - Coding Decisions
(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);
Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013
(Implementation of VMS)
Where used in this Chapter, the term “coding decisions" generally refers to MR
decisions. For example, coding decisions include each of the following:
• 	Contractor reviews product information for a durable medical equipment
prosthetics, orthotics, and supplies (DMEPOS) item, finds that the wrong code
has been billed based upon the review of diagnoses codes and narrative
information included on the claim/bill, changes the code to the correct code, and
completes the claim.
In the situation described above, the Contractor denies the claim line with the
wrong code and uses the message that the supplier has incorrectly coded the item.
• 	The Contractor determines that a service billed as a bilateral x-ray is a single view
x-ray and indicates a down code to a single view x-ray in the remittance advice.
Include only coding decisions that require the application of clinical judgment as
part of a review, in writing policies, or in the development of guidelines and
processing instructions.
7.2.4 - Monthly Reporting of Medical Review Savings
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
The Contractor shall utilize the definitions in their statement of work (SOW) to report
those savings resulting from medical review. The report shall be submitted by the 20 th
day of each calendar month and submitted as a deliverable via the CMS ART portal. The
activities and metrics to be reported for calculating Medical Review Savings are detailed
in the spreadsheet below. The template, developed by the Provider Compliance Group,
includes the formulas required to calculate MR savings and shall not be altered or
deviated from.
Complete printed PDF page 22
Medical Review Savings Report Template Sample next page.
(Medical Record Review (MRR))
7.3 - The Strategy Analysis Report (SAR)
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
7.3.1 - General Overview
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The purpose of the SAR is to assess progress towards achieving the improvement goals
set out by the IPRS. The SAR shall analyze the specific results of the MAC’s current
IPRS by using a systematic, data-guided evaluation of all aspects of the IPRS:
Complete printed PDF page 23
• 	the listed prioritized problems
• 	current changes to the baseline problem measurements specific to each prioritized
problem
• 	progress or lack of progress towards accomplishment of the improvement goals
specific to each prioritized problem
• 	effectiveness of the specific MR activities
• 	improper payment interventions
• 	improvement of provider billing behavior
The SAR encapsulates the previous IPRS and uses that information to reassess, modify or
to continue with the current planned approach to demonstrate progress towards their
stated improvement goals for the current period of performance.
7.3.2 - SAR Required Format
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
7.3.2.1 - Cover Page
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The cover page shall include the following information:
• 	MAC name and address
• 	MAC contract number
• 	States in jurisdiction
• 	Period of performance (explanation shall be included if the SAR is reporting on a
period of performance less than 6 months)
• 	Report coordinator contact information (name, telephone number and e-mail
address)
• 	SAR due date and submission date
7.3.2.2 - Overview/Executive Summary
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The executive summary of the SAR shall provide a brief, high-level summation of overall
MR program requirements enacted and any progress, changes, or updates since the
submission of the IPRS. This section shall address important projects and CMS
requirements that are not captured under the Prioritized Problem List and addressed in the
IPRS.
The MAC shall not cut and paste the Overview/Executive Summary from the previous
IPRS into the SAR. If there are no changes from information submitted in the previous
IPRS, the MAC shall state “no changes from IPRS submitted on x date.”
7.3.2.3 - Prioritized Problem List
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
Complete printed PDF page 24
The SAR requires the MAC to assess their prioritized IPRS problem list and report on
that assessment to date. The SAR shall summarize the MR activities, improper payment
interventions, and MR activities taken to address each of the identified prioritized
problems in the MAC’s IPRS.
This section shall include details on both prioritized problems that were contained in the
IPRS, in addition to newly identified problems. Units or measurements used to quantify
baseline problem measurements, improvement goals, and the achievement or non-
achievement of the improvement goals shall be consistent throughout the SAR and IPRS.
For each specific prioritized problem on the IPRS problem list, the MAC shall provide
the following information:
A. Prioritized problem description.
Each prioritized problem on the problem list shall include a problem description. This
section shall contain a brief description of problem characteristics and associated planned
MR activities and improper payment interventions. The MAC shall include information
regarding how the problem was identified (i.e., CERT, Recovery Auditor, CMS, OIG,
Comparative Billing Report (CBR), MAC internal data analysis, GAO, etc.)
Duplication of the details contained in the IPRS is not needed; rather, the MAC may refer
the reader to the previous IPRS for detailed descriptions, as required. The reader should
easily see that the problems already identified and defined in the IPRS correspond to the
SAR’s listing of numbered problems.
The MAC shall also provide the problem identification number or case number (if used)
that is not the ranking number of the prioritized problem. This number shall be consistent
in the IPRS and the SAR.
B. Whether the prioritized problem is a new or carry-over problem from the IPRS.
The MAC shall report on both the problems that were identified in the IPRS as well as
problems that have been added to the IPRS prioritized list as a result of data analysis.
Any prioritized problem removed since the last IPRS shall be explained.
For problems that have been newly identified and added to the SAR subsequent to the
IPRS submission, a detailed narrative is appropriate.
7.3.2.4 - MR Activities and Improper Payment Interventions Planning
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall provide updates on MR activities and other improper payment
interventions planned and/or continued in order to improve the problem and meet
Complete printed PDF page 25
improvement goals. The MAC shall provide updates on the information described in the
IPRS. 	Such information includes, but is not limited to:
• 	Baseline problem measurement reported in IPRS compared to problem
measurement after intervention implementation (may be provider-specific and/or
service-specific). The baseline problem measurement from the IPRS and current
problem measurement in the SAR shall be the same type of error measurement that
was stated in the IPRS.
• 	Differences in the number of providers and/or services undergoing MR activities
and other intervention as reported in the IPRS as what has been observed at the
time the SAR is finalized.
• 	Improvement goal revisions, as appropriate. Effectiveness of the MR activities
and improper payment interventions in meeting the goal shall be addressed. These
updates shall be stated in measureable terms that are data driven.
• 	Any identified obstacles regarding the MR activities or improper payment
interventions to achieve the improvement goal and suggestions for improvement.
• 	For each prioritized problem, the contractor shall report on probe reviews
conducted, as appropriate. Detailed information shall include:
o 	Number of probe reviews identified:
The number of probe reviews the MAC planned for a specific
problem and the type of data and/or analysis used to determine the
number of probes.
o 	Number of probe reviews initiated:
A subset of the number identified. This number conveys the actual
number of probe reviews effectuated to date. Generally, the probe
initiation date is the date a request for medical records is sent to the
provider(s). The date of the probe start shall be included.
o 	Type of probe review (i.e., pre-pay vs. post-pay, provider-specific vs.
service specific)
o 	Number of probe reviews completed:
This number conveys the number of probe reviews concluded. It is
the number of probe review cases for which corrective action has
been initiated.
o 	Probe Results: current problem measurement determined by the probe,
progress towards goal, effectiveness of probe edit.
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• 	For each prioritized problem , the contractor shall report on targeted reviews
conducted, as appropriate: Detailed information shall include:
o 	Number of targeted reviews identified:
The number of targeted reviews as well as the subject of targeted
reviews (benefit, provider type, and provider specific) that the
MAC planned for a specific problem, and the type of data and/or
analysis used to determine the number.
In the case of more than one service within a benefit or provider
type, the benefit or provider type should be grouped under a
general heading in the problem description. However, when
reporting the number of identified target reviews planned, the SAR
should clearly report the number planned for each code, or range of
codes representing the specific service or provider type (Diagnosis
Related Group (DRG), Healthcare Common Procedure Coding
System (HCPCS), ICD-10) within the benefit or service
description. An example is, “Physical Medicine & Rehabilitation:
the total number identified for targeted reviews is x number. For
physical medicine & rehabilitation CPT code XXX-traction,
mechanical, x number of targeted reviews are planned. For
physical medicine & rehabilitation code range XXX1-XXX3,
therapeutic procedures, x number of targeted reviews are identified
(for a total of x number of identified target reviews).” Start date of
the targeted review and baseline problem measurement shall be
included.
Similarly, if targeted reviews are planned for specific providers,
the total number of providers, the states in which they practice and
the service, procedure or diagnosis codes subject to the specific
provider targeted claims shall be included in the SAR. An
example is, “ESRD, dialysis centers: x number of centers have
been identified for targeted reviews. The focus for each dialysis
center on targeted review will be XXX CPT Code, extra
hemodialysis session. For each center identified, x number of
targeted reviews are planned.” 	The start date and the baseline
problem measurement shall be included.
o 	Number of targeted reviews initiated:
This number is a subset of the number described above, “Number
Identified”. It is the actual number of providers or services
activated for targeted review. As described earlier, the SAR shall
clearly identify the focus of the targeted review: the procedure,
diagnosis or DRG code, or place of service, etc. The percentage of
claims to be stopped by an edit for each targeted review shall be
included.
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o 	Type of targeted review (i.e., random v. 100 percent, pre-pay v. post-pay,
provider-specific v. service-specific)
o 	Number completed:
This number conveys the number of targeted reviews concluded. It is the
number of targeted review cases for which corrective action has been
initiated.
o 	Targeted Review Results: current problem measurement, progress towards
goal, effectiveness of edit.
• 	Other MR activities and improper payment interventions taken to address the
specific prioritized problem and the effectiveness of the interventions.
If analysis of the MR activities and other improper payment interventions shows that the
improvement goals have been achieved for a specific prioritized problem, the MAC shall
determine if the improved provider billing behavior or decrease in IPR is sustainable. If
so, the MAC shall consider closing that problem and/or reprioritizing their problem list.
The MAC shall include a description of the analysis used to make the determination that
the improvement goal was met and rationale to support the closing and/or reprioritizing
of the problem.
Conversely, if the results of the SAR convey ineffectiveness of the MR activities and
improper payment interventions, the SAR shall include modified plans for the areas of
ineffectiveness of the IPRS. 	The result of this analysis shall lead the MAC to design
future MR activities and improper payment interventions aimed at achieving the revised
or same improvement goals.
7.3.2.5 - Program Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
7.3.2.5.1 - Budget and Workload Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The SAR shall include a narrative that describes any significant fluctuations in the MR
workloads and MR budget since the previous IPRS. The MAC shall include a table
identifying any modification made to MR workload since the previous IPRS.
Complete printed PDF page 28
7.3.2.5.1.1 - Workload Reporting Tables
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
SAR/Medical Review Program Workload A/B MAC and HHH MAC
SOW 	MR
Activity
Part A
Projected
Workload
for this
Period of
Performance
Part B
Projected
Workload
for this
Period of
Performance
Home Health
Projected
Workload for
this Period of
Performance
Hospice
Projected
Workload
for this
Period of
Performance
Modifications/
Changes since
the previous
IPRS
C.5.12.1.6 	Defending
MR
Decisions
at ALJ
Hearings
C.5.12.2.1 	Automate
d Medical
Review
C.5.12.2.2 	Non-
Medical
Record
Review
C.5.12.2.3 	Demand
Bill
Claims
Review
C.5.12.2.4 	Medical
Review
Reopening
C.5.12.2.5 	Prepay
Provider
Specific
Medical
Record
Review
C.5.12.2.6 	Prepay
Service
Specific
Medical
Record
Review
C.5.12.2.7 	Prepay
Probe
Provider
Complete printed PDF page 29
SOW 	MR
Activity
Part A
Projected
Workload
for this
Period of
Performance
Part B
Projected
Workload
for this
Period of
Performance
Home Health
Projected
Workload for
this Period of
Performance
Hospice
Projected
Workload
for this
Period of
Performance
Modifications/
Changes since
the previous
IPRS
Specific
Medical
Record
Review
C.5.12.2.8 	Prepay
Probe
Service
Specific
Medical
Record
Review
C5.12.2.10 	Postpay
Probe
Provider
Specific
Medical
Record
Review
C.5.12.2.11 	Postpay
Probe
Service
Specific
Medical
Record
Review
C.5.12.2.12 	Postpay
Provider
Specific
Medical
Record
Review
C.5.12.2.13
Postpay
Service
Specific
Medical
Record
Review
C.5.12.2.17 	Externally
Directed
Reviews
Complete printed PDF page 30
SOW 	MR
Activity
Part A
Projected
Workload
for this
Period of
Performance
Part B
Projected
Workload
for this
Period of
Performance
Home Health
Projected
Workload for
this Period of
Performance
Hospice
Projected
Workload
for this
Period of
Performance
Modifications/
Changes since
the previous
IPRS
C.5.12.2.18 	Provider
Complian
ce Group
Directed
Reviews
C.5.12.2.20 	One on
One
Education
SAR/Medical Review Program Workload DME MAC
SOW 	MR Activity 	DME
Workload for
this Period of
Performance
DME Budget
for this
Period of
Performance
Modifications/
Changes Since the
Previous IPRS
4.7.1 	Automated Medical
Review
4.7.2 	Non-Medical Record
Review
4.7.3 	Demand Bill Claims
Review
4.7.4 	Medical Review
Reopening
4.7.5 	Prepay Medical Record
Review Provider Specific
4.7.6 	Prepay Medical Record
Review Service Specific
4.7.7 	Prepay Medical Record
Review Probe Review
Provider Specific
4.7.8 	Prepay Medical Record
Review Probe Review
Service Specific
Complete printed PDF page 31
SOW 	MR Activity 	DME
Workload for
this Period of
Performance
DME Budget
for this
Period of
Performance
Modifications/
Changes Since the
Previous IPRS
4.7.10 	Postpay Medical Record
Review Probe Review
Provider Specific
4.7.11 	Postpay Medical Record
Review Probe Review
Service Specific
4.7.12 	Postpay Medical Record
Review Provider Specific
4.7.13 	Postpay Medical Record
Review Service Specific
4.7.17 	Externally Directed
Reviews
4.7.18 	Provider Compliance
Group Directed Reviews
4.7.22 	One on One Education
4.12 	Defending MR Decisions
at ALJ Hearings
7.3.2.5.2 - Staffing and Workload Management
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MACs shall also detail in a narrative any significant fluctuations in staffing or issues
with workforce management as appropriate since the previous IPRS.
7.3.3 - Quality Assurance Plan
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The SAR shall include a narrative section titled Quality Assurance (QA) that describes
the QA processes actually used since the submission of the previous IPRS. The QA
Complete printed PDF page 32
process information includes, but is not limited to, descriptions for continuous
monitoring/surveillance and improvement of the following processes:
• 	How the MAC monitored the quality of reviews
• 	Results of the IRR assessments of the MR licensed health care professionals
clinical reviewers, and coders from the previous IPRS
• 	How methods of data analysis were selected, validated and employed
• 	How edit effectiveness was assessed for each prioritized problem (identify the
MAC’s threshold for deeming an edit effective; discontinuing an edit)
• 	How the MAC closely monitored the impact of MR activities and improper
payment interventions specific to each problem on the prioritized problem list and
their overall improper payment rate
• 	How the MAC recorded improvement opportunities for their internal use
• 	How any new processes were introduced to their MR business operations
• 	Any other information the MAC believes is pertinent to their QA efforts
The narrative information shall not include a restatement from the IPRS; rather, the QA
section should be used to communicate the QA processes used since the submission of
the previous IPRS as well as those planned for future months. The MAC shall also
include an explanation for changes in problem priority, rationale for changes in workload
or budget, or new initiatives directed by CMS that required the MAC to suspend
activities described in the IPRS.
7.3.4 - SAR Submission
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall submit a SAR as directed by the SOW and COR. The current SAR shall
be updated or revised as required by the COR after review by the MR, CERT and POE
BFLs and the RO TM staff.
7.3.5 - SAR Revision
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall notify their COR, RO TM and the MR BFL when their SAR requires a
revision/update of the final approved SAR. The revision/update shall be included in the
current monthly status report under the A/B MAC Medical Review section, K7 and under
the Medical Review section for the DME MACs. The SAR revision shall be noted in the
next strategy due deliverable. This deliverable could be either the IPRS or SAR.
Complete printed PDF page 33
Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R10365PI 10/02/2020 	Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10,
11, and Exhibits of Publication (Pub.) 100-08
08/272020 	11884
R10228PI 07/27/2020 	Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10,
11, and Exhibits of Publication (Pub.) 100-08
Rescinded and Replaced by Transmittal
10365
08/27/2020 11884
R835PI 	10/12/2018 	One-on-One Education 	11/13/2018 10963
R721PI 	06/09/2017 	Elimination of Routine Reviews Including
Documentation Compliance Reviews and
Instituting Three Medical Reviews
07/11/2017 9809
R663PI 	07/15/2016 	Denial Codes for Missing or Insufficient
Documentation
08/16/2016 9690
R642PI 	02/22/2016 	Medicare Program Integrity Changes - Pub.
100-08 Chapter 7
02/16/2016 9497
R633PI 	01/15/2016 	Medicare Program Integrity Changes - Pub.
100-08 Chapter 7 – Rescinded and replaced
by Transmittal 642
02/16/2016 9497
R607PI 	08/12/2015 	Workload Reporting 	09/03/2015 9215
R600PI 	07/02/2015 	Workload Reporting – Rescinded and
replaced by Transmittal 607
09/03/2015 9215
R599PI 	06/26/2015 	Annual Improper Payment Reduction
Strategy (IPRS)
12/07/2015 9172
R550PI 	10/31/2014 	One on One Education 	12/02/2014 8964
R444PI 	12/14/2012 	Retirement of the Program Integrity
Management Reporting (PIMR) System
04/01/2013 8093
R441PI 	11/23/2012 	Retirement of the Program Integrity
Management Reporting (PIMR) System –
Rescinded and replaced by Transmittal 444
04/01/2013 8093
R313PI 	11/20/2009 	Program Integrity Manual (PIM)
Reorganization Chapters 1, 2, and 7
12/21/2009 6546
R237PI 	02/01/2008 	PIMR Annual Update 	03/03/200/ 5706
R229PI 	11/23/2007 	Medical Review Strategy and Strategy
Analysis Report
04/07/2008 5760
R220PI 	08/24/2007 	Various Medical Review Clarifications 	09/03/2007 5550
R203PI 	05/25/2007 	Strategy Analysis Report 	07/02/2007 5519
R174PI 	11/17/2006 	Transition of Medical Review Educational
Activities
10/06/2006 5275
Complete printed PDF page 34
Rev # 	Issue Date 	Subject 	Impl Date CR#
R171PI 	11/03/2006 	Transition of Medical Review Educational
Activities – Replaced by Transmittal 174
10/06/2006 5275
R163PI 	09/29/2006 	Transition of Medical Review Educational
Activities – Replaced by Transmittal 170
10/06/2006 5275
R103PI 	02/04/2005 	Discontinuation of Medical Review Reports -
The Medicare Status Report MRS-1), the
Report of Benefit Savings (RBS), the
Medicare Focused Medical Review Status
Report (MFSR), and the Focused Medical
Review (FMR) Report
03/07/2005 3701
R081PI 	07/23/2004 	Implementation of the Quarterly Strategy
Analysis
08/23/2004 3294
R073PI 	05/07/2004 	Business Requirements for CR3030 	06/10/2004 2646
R071PI 	04/09/2004 	Rewrite of Program Integrity Manual (except
Chapter 10) to Apply to PSCs
05/10/2004 3030
R062PI 	01/23/2004 	Focused Medical Review Report 	04/05/2004 3062
R052PI 	10/10/2003 	FY 2004 Conversion Factors for the Report
of Benefit Savings
01/01/2004 2915
R045PI 	07/25/2003 	FMR Activity Report 	08/08/2003 2693
R016PIM 11/28/2001 	Adds Various Program Memoranda for BI
Requests for Information, Organizational
Requirements, Unsolicited Voluntary Refund
Checks, Anti-Kickback Statute Implications
11/28/2001 1732
R003PIM 11/22/2000 	Complete Replacement of PIM Revision 1. 	NA 	1292
R001PIM 06/2000 	Initial Release of Manual 	NA 	931
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