Prepayment Review definition

Prepayment Review means a specific review of identified Claims or services or types of Claims or services prior to determination and payment in order to prevent improper payments due to a sustained or high level of payment error or resulting from an analysis that identifies a problem related to possible Fraud, Waste, and/or Abuse.

Prepayment Review means any action by the health plan, contracting entity,

Prepayment Review or "PPR" means a departmental review of a claim regarding a recipient who is not enrolled with a managed care organization to determine if the requirements of this administrative regulation have been met prior to authorizing payment.

Examples of Prepayment Review in a sentence

• State Laws that Affect Prepayment Review Timeliness Requirements The MACs shall adhere to state laws that require an evidentiary hearing for the beneficiary before any denials are processed.

• Prepayment Review Requirements for MACs When a MAC receives requested documentation for prepayment review within 45 calendar days of the date of the ADR, the MAC shall do the following within 30 calendar days of receiving the requested documentation: 1) make and document the review determination and 2) enter the decision into the Fiscal Intermediary Shared System (FISS), Multi-Carrier System (MCS), or the VIPS Medicare System (VMS).

• Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued.

• Prepayment Review Requirements for UPICs When a UPIC receives all documentation requested for prepayment review within 45 calendar days of the date of the ADR, the UPIC shall make and document the review determination and notify the MAC of its determination within 60 calendar days of receiving all requested documentation.

• Limits on Automated Prepayment Review The MACs shall not install edits that result in the automatic denial of payment for items or services based solely on the diagnosis of a progressively debilitating disease when treatment may be reasonable and necessary.

• Yaghootkar H, Lamina C, Scott RA, Dastani Z, Hivert MF, Warren LL, et al..

• The MassHealth agency pays for procedures and acute hospital stays that are subject to the acute hospital Utilization Management Program only if the applicable requirements of the program as described in 130 CMR 450.207: Utilization Management Program for Acute Inpatient Hospitals through 450.209: Utilization Management: Prepayment Review for Acute Inpatient Hospitals are satisfied.

• Prepayment Review Requirements for MACsWhen a MAC receives requested documentation for prepayment review within 45 calendar days of the date of the ADR, the MAC shall do the following within 30 calendar days of receiving the requested documentation: 1) make and document the review determination and 2) enter the decision into the Fiscal Intermediary Shared System (FISS), Multi-Carrier System (MCS), or the VIPS Medicare System (VMS).

• This results in denial of payment by HFS for the entire stay.Notice of Preoperative Day(s) Denial – Prepayment Review – This notice is issued when a PR is unable to substantiate the medical necessity of the one or more preoperative days.

• NOTE: The billing of beneficiaries is prohibited for services denied through Prepayment Review.