Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g. complaints);
  • Reviews data analysis reports;
  • Takes action to prevent and/or address the identified error;
  • Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute.

Additional Resources:

Latest Articles

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Active Medical Reviews 04/23/2019
Responding to a Home Health Additional Documentation Request (ADR) 01/07/2019
April - June 2018 Home Health Medical Review Top Denial Reason Codes 12/18/2018
Medical Review Intent to Reopen Process for Non-Receipt of Medical Record Denials 08/10/2018
Home Health Medical Review Denials 08/02/2018
Alabama Medical Review Denials 08/01/2018
Arkansas Medical Review Denials 08/01/2018
Florida Medical Review Denials 08/01/2018
Georgia Medical Review Denials 08/01/2018
Illinois Medical Review Denials 08/01/2018
Indiana Medical Review Denials 08/01/2018
Kentucky Medical Review Denials 08/01/2018
Louisiana Medical Review Denials 08/01/2018
Mississippi Medical Review Denials 08/01/2018
New Mexico Medical Review Denials 08/01/2018
North Carolina Medical Review Denials 08/01/2018
Ohio Medical Review Denials 08/01/2018
Oklahoma Medical Review Denials 08/01/2018
South Carolina Medical Review Denials 08/01/2018
Tennessee Medical Review Denials 08/01/2018
Texas Medical Review Denials 08/01/2018
Top 10 Home Health Medical Review Denials Module Open in New Window07/17/2018
Medical Review Requirements for Home Health Face-to-Face Documentation 07/16/2018
Hospice Medical Review Top Denial Reason Codes: April - June 2018 07/13/2018
Responding to a Hospice Additional Documentation Request 06/08/2018
Non-Physician Practitioners and the Face to Face Encounter 04/09/2018
HHH Reason Code Crosswalk 02/09/2018
Medicare Record Authentication: Tips for Physicians 02/07/2018
Palmetto GBA Partnering with Providers to Get it Right the First Time 02/07/2018
Complying with Medicare Signature Requirements Open in New Window02/02/2018
Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices 02/02/2018
Charge Denial Rate (CDR) Calculator Open in New Window01/05/2018
We Have Noticed a Significant Increase in 56900 Auto Denials - Requested Records Not Submitted 12/19/2017
Home Health: Therapy ADRs 10/05/2017
Home Health Medical Review Denials 08/02/2017
Hospice Certification Errors 08/02/2017
Hospice Documentation Tips 03/09/2017

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Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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