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Medical review

Hot topics
more Medicare Administrative Contractor’s Resume Medical Review on a Post-Payment Basis
To protect the Medicare Trust Fund against inappropriate payments, Medicare administrative contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs are resuming with post-payment reviews of items/services provided before March 1. The targeted probe and educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.
more Targeted probe and educate – temporarily postponed
Targeted probe and educate (TPE) reviews have been temporarily postponed due to the public health emergency (PHE) declared as a result of the 2019 novel coronavirus (COVID-19). We encourage providers to focus on patient care and defer discussions related to these reviews after the PHE. First Coast will reach out to providers after the pandemic to offer education based upon prior reviews. In the event providers would like to receive education during this time, we are prepared to provide educational sessions. Please feel free to reach out to the nurse assigned to your case to arrange an educational call.
Targeted probe and educate
CMS has authorized First Coast to conduct reviews utilizing a targeted probe and educate (TPE) review process. View current and upcoming topics, schedules, documentation checklists, educational articles / resources and round results.
Prior authorization
Learn more about the prior authorization (PA) program, including the implementation of the PA program for certain hospital outpatient department (OPD) services.
Post-payment service-specific review
Medical review of claims helps to ensure that Medicare pays for services that are covered, correctly coded, and medically reasonable and necessary.
Medical documentation and checklists
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. Find tips, tools and resources for the documentation of clinical services provided to Medicare patients. Use the checklists to ensure you have met medical documentation requirements based on specific services.
Medical Review contacts
Contact the Medical Review mailboxes below for general medical review questions. It is monitored daily during regular business hours. Do not include any protected health information (PHI) or personally identifiable information (PII).
Comprehensive Error Rate Testing (CERT)
Contact the First Coast Service Options CERT team at QUESTCERT@fcso.com. Use this mailbox for general CERT questions or to check the status of a CERT review. It is monitored daily during regular business hours. Please be sure to include the CID and contract number or state. Do not include PHI or PII.
Quick clicks
The Secure Provider Online Tool (SPOT) is a free web based application hosted through the Centers for Medicare & Medicaid Services (CMS) Enterprise Identity Management (EIDM) portal. SPOT saves you valuable time by offering the ability to view medical review-related additional documentation requests (MR ADR), education details, submit a response with supporting documentation, and check MR ADR status. SPOT users can also view eligibility data, submit and view level-one appeals outcomes, check claim status, access remittance details, and more.
With today's transition to automation, it is even more important to ensure that your physical and mailing address information are kept current with your Medicare administrative contractor.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.