Medical review activities
Service-specific reviews
First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. Medical review of claims helps to ensure that Medicare pays for services that are covered, correctly coded, and medically reasonable and necessary.
Low biller probe and educate
Low biller probe and educate (P&E) has been created to improve the medical review/education process, reduce appeals and lower the improper payment rate by targeting and educating low claim volume billing providers that would otherwise not typically be included in the targeted probe and educate (TPE). This medical review is for providers/suppliers who bill five to 19 claims within a three-month period. Providers who demonstrate compliance with CMS requirements will be released from review for approximately one year.
Part A skilled nursing facility (SNF)
Learn more about the Part A SNF P&E reviews that require all MACs to perform a 5-claim probe and educate medical review on every SNF in their jurisdiction.