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Medical review

Hot topics
more Learn how to electronically submit your claims, medical records, and other correspondence. Part A | Part B
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.
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Skilled nursing facility (SNF) 5-claim probe and educate (P&E) review
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.
Prior authorization
Learn more about the prior authorization (PA) program, including the implementation of the PA program for certain hospital outpatient department (OPD) services.
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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.
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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.
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Low biller probe and educate (P&E) program
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.
Medical Review contacts
Medical Review related questions should be directed to your nurse reviewer. For general information, please call the contact center to speak to a customer service representative or complete a general inquiry request form. Do not include any protected health information (PHI) or personally identifiable information (PII) in the online forms or emails.
How satisfied are you with the Medical Review process?
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.
Part A