100% Prepayment Review and Random Review Instructions

October 28, 2013
 / 
Rick Gawenda
 / 

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.

To read the full instructions, click

The content here is for members only log in here or sign up.


All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.

This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

There are currently no comments.