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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.

About Robert Hoover, MD, MPH, FACP – Chief Medical Officer About Robert Hoover, MD, MPH, FACP – Chief Medical Officer Other Medical Review Contractors Other Medical Review Contractors
ADMC Advance Determination of Medicare Coverage (ADMC) Physician's Corner Physician's Corner
Artificial Limbs, Braces, Other Custom Made Items Artificial Limbs, Braces, Other Custom Made Items CPPA Prior Authorization
Medical Review Resources CGS Connect Medical Review Resources Provider 360
DME MAC Joint Publications DME MAC Joint Publications TPE Quarterly Reports by Policy Quarterly Status Reports
Education Programs Education Programs Medical Review Resources Resources
LCDs/Policy Articles LCDs/Policy Articles Serial Claims Review Initiative Serial Claims Review Initiative
Q&As MR Q&As Targeted Probe and Educate (TPE) Targeted Probe and Educate (TPE)

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