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What Is Medical Review?

One of the top priorities of the Centers for Medicare & Medicaid Services (CMS) is addressing improper payments in the Medicare fee-for-service program. CMS contracts with different types of contractors to achieve the goal of reducing improper payments. These contractors are:

CMS also strives to protect the program from potential fraud by contracting with Zone Program Integrity Contractors (ZPICs) to identify and stop potential fraud.

CGS is the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C. CGS uses error rates produced by the CERT program and vulnerabilities identified through data analysis and medical review of claims to determine where to target their improper payment prevention efforts.

Medical Review is one of the CGS departments involved with preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies. 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:

Medical review activities performed at CGS also include processing Advance Determination of Medicare Coverage (ADMC), Power Mobility Prior Authorization Demonstration Project and CGS Connect requests.

CMS has prepared a brochure, Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT and Recovery Audit ProgramExternal PDF, for anyone who would like additional information about Medicare clam review programs including MAC medical review activities and responsibilities.

Related Information

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This page was last modified/reviewed on: 9/29/2015
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