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