NGS Medical Review Process

Medicare contractors, like NGS, operate the medical review program to prevent improper payments and protect the Medicare Trust Fund. Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing and medical necessity requirements.

Medical review identifies errors through claim analysis and/or medical record review activities. Contractors use this information to help ensure they provide proper Medicare payments (and recover any improper payments if the claim was already paid). Contractors also offer education to help ensure future compliance. A Medicare contractor may use any necessary information to make a claim review determination, including any documentation submitted with the claim or through an additional documentation request.

If you would like information about our TPE program, please visit the TPE Home Page and review our Best Practices for a Successful Targeted Probe and Educate article.

Educational Videos

Reviewed 6/26/2024