Medical Review
The mission of Medical Review (MR) is to reduce supplier billing errors and ensure that Medicare claims are paid correctly while maintaining the Medicare Program integrity. To reduce claim submission (coverage/coding) and payment errors, and increase timely payments, data is gathered and errors are identified and addressed.
The CGS Medical Review department consists of a Medical Director, registered nurses and other clinicians, and specially trained support staff. To achieve the goals of CMS's MR program, CGS Medical Review:
- Identifies supplier noncompliance with coverage, coding, billing, and payment policies through analysis of data and evaluation of other information;
- Acts early and often to prevent and/or address the identified improper payment; and
- Place emphasis on reducing the paid claims error rate by notifying suppliers of review findings, providing education, and making appropriate referrals to supplier outreach and education (POE), and other Medicare contractors
Medical review activities performed at CGS also include processing Advance Determination of Medicare Coverage (ADMC), Prior Authorization, and CGS Connect requests.