Skilled nursing facility (SNF) 5-claim probe and educate (P&E) review

Change request 13164 requires that all MACs perform a 5-claim probe and educate medical review on every SNF in their jurisdiction. The purpose of this widespread review is to lower the SNF improper payment rate. If the MAC identifies an improper payment the MAC will adjust the individual claim payment, as appropriate, in addition to providing education, including their explanation for denial or adjustment of payment.

At the conclusion of the SNF 5-claim review project, the MAC shall prioritize TPE review of providers who were found to have five out of five claims in error.

For additional information go to: MLN Matters article MM13164: Skilled nursing facility probe and educate review.