Medicare Basic Training Part 10: Medical Review and Appeals On-Demand Workshop

The SNF Medicare claims processing system is based largely on the honor system. A claim is submitted to the Medicare Administrative Contractor and is paid without the SNF first being asked for evidence that items on the bill occurred or met Medicare requirements for billing. Medical review is the process of reviewing a portion of claims to determine whether services provided were medically reasonable and necessary, as well as to follow up on the effectiveness of previous corrective actions. Following Medicare Basic Training Part 10: Medical Review and Appeals, you will be able to describe the medical review process including what to do when a request for medical records comes in and how to proceed if the decision is not in the facility’s favor.