100% Prepayment Review and Random Review Instructions

The Centers for Medicare and Medicaid Services (CMS) has released instructions to the MACs on 100% Prepayment Review and Random Review. Random review is defined as review conducted without a specific reason or logic to substantiate the cause for review. MACs have the discretion to conduct random reviews of services; however, CMS does not recommend random reviews. 100% prepayment review is defined as review of every claim submitted by a targeted provider for a specific code (i.e. DRG, CPT, HCPCs). 100% prepayment review also includes review of every claim submitted by the targeted provider.
MACs have the discretion to conduct 100 % prepayment review of providers. CMS considers 100 % prepayment review to be appropriate when a provider has a prolonged time period of non-compliance with CMS policies.

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