TL;DR
Chapter 3 of the Medicare Program Integrity Manual (Pub. 100-08) is the rulebook contractors follow when they review claims. It explains prepayment and postpayment review, additional documentation requests and the 45-day response time, Targeted Probe and Educate, the documentation and signature standards reviewers apply, how review determinations are made, the corrective actions that follow, and prior authorization.
Chapter 3 at a glance
- Current revision
- Rev. 13821
- Issued June 9, 2026
- Effective
- February 26, 2026
- Implemented February 26, 2026
- Sections
- 80
- 10 top-level sections
- Transmittals in history
- 146
- Listed at the end of the chapter
- Monthly searches
- 90
- Google Ads, US, October 2026
What chapter 3 governs for billing
Section 3.2 sets out how contractors select and review claims. MACs, Recovery Audit Contractors, the CERT contractor and Unified Program Integrity Contractors all follow it. When review needs records, the contractor sends an additional documentation request, and under 42 CFR 405.929 the provider has 45 calendar days to respond (3.2.3.2). The section covers third-party requests, acceptable submission methods including electronic submission, payment for copies, what happens when no response or an insufficient response arrives, and how a claim denied for late records can be reopened (3.2.3.8 and 3.2.3.9). Section 3.2.5 describes Targeted Probe and Educate: a round typically reviews 20 to 40 claims per provider, with education after each round, repeated for up to three rounds before a provider that remains noncompliant is referred to CMS.
Section 3.3 is the documentation standard that decides most reviews. Reviewers base determinations on the medical record and the policies that apply, including NCDs, LCDs and MAC articles (3.3.2 and 3.3.2.8). They read progress notes and templates (3.3.2.1.1), check that the record is signed by the author, accepting a signature attestation or signature log when a signature is missing or illegible (3.3.2.4), and judge whether amendments, corrections and late entries were made properly (3.3.2.5). Section 3.3.3 explains how contractors review claims where no policy exists.
Sections 3.4 to 3.7 cover the review process itself: prepayment edits and how LCD and NCD numbers are linked to them (3.4), postpayment record review and reopening of paid claims (3.5), the types of determinations reviewers make, from full and partial denials to adjustments in the level of service (3.6), and the corrective actions that follow, such as overpayment recovery, education, more targeted review or referral (3.7). The chapter ends with relief from review during disasters (3.8), how contractors defend their decisions at administrative law judge hearings (3.9) and prior authorization programs, in which a request receives a provisional affirmative or non-affirmative decision before the service (3.10).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 3 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 3.2.3.1 | Additional Documentation Requests (ADR). | What an additional documentation request contains and who receives it. |
| 3.2.3.2 | Time Frames for Submission | The 45-calendar-day timeframe to respond to an ADR. |
| 3.2.3.8 | No Response or Insufficient Response to ADRs | What happens when there is no response or an insufficient response. |
| 3.2.5 | Targeted Probe and Educate (TPE) | Targeted Probe and Educate: 20 to 40 claims a round, up to three rounds. |
| 3.3.2.4 | Signature Requirements | Signature requirements, attestation statements and signature logs. |
| 3.3.2.5 | Amendments, Corrections and Delayed Entries in Medical Documentation | Amendments, corrections and delayed entries in medical documentation. |
| 3.10 | Prior Authorization | Prior authorization and provisional affirmation decisions. |
How chapter 3 shows up on claims and denials
A claim selected for review and not supported by records within 45 days is denied, and the remittance typically pairs a denial reason with remark N102, records not received or not received timely, or M127, missing patient medical record. Those denials can be reopened when the records are later submitted, as section 3.2.3.9 describes, which is often faster than an appeal. Records that arrive but do not support the service lead to a medical necessity denial, reason code 50, or to a partial denial or adjusted level of service.
Most avoidable review losses trace to the documentation standards in section 3.3: an unsigned order or note without an attestation, a template entry that does not show the individual patient's condition, or an amendment made after the request without a clear date and reason. A TPE round that ends with an error rate above the contractor's threshold leads to another round and education rather than an immediate penalty, but continued errors after three rounds go to CMS for further action.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| N102 | Remark code | Denied without review because requested records were not received or not received timely. |
| M127 | Remark code | Missing patient medical record for this service. |
| 50 | Claim adjustment reason code | Records reviewed do not support medical necessity. |
| 252 | Claim adjustment reason code | An attachment or other documentation is required to adjudicate the claim. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13821, issued June 9, 2026, effective February 26, 2026, implemented February 26, 2026. That revision changed sections 3.2.3.1 (Additional Documentation Requests (ADR).), 3.2.3.2 (Time Frames for Submission), 3.2.3.5 (Acceptable Submission Methods for Responses to ADRs), 3.6.4 (Notifying the Provider).
The newest rows of the transmittal history printed at the end of the chapter (146 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R13595PI | January 26, 2026 | Updates of Chapters 3, 4, and Exhibits in Publication (Pub.) 100-08, Including Updates to the Provider Notification Process and Vetting with the CMS Process | 14362 |
| R13008PI | December 18, 2024 | Chapter 3 Revisions (Segment 1) in Publication (Pub.) 100-08 Program Integrity Manual (PIM) | 13735 |
| R12633PI | May 9, 2024 | Medical Review Policies for Signature Requirements | 13556 |
| R12056PI | May 25, 2023 | Update to Chapter 3 of Publication (Pub.) 100-08 (Program Integrity Manual (PIM)) for the Voluntary Prior Authorization (PA) Process for Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Accessories | 13185 |
| R11933PI | March 30, 2023 | Update to Process and Responsibility for Tracking Medicare Contractors' Prepayment and Post Payment Reviews in the RAC Data Warehouse (RACDW) | 12281 |
| R11529PI | July 28, 2022 | Update of Chapter 3 in Publication (Pub.) 100-08, Including Update to Medicare Program Integrity Contractor Post-Payment Review Process, and Update of Chapter 8 Pub. 100-08, Including Revision to When | 12827 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 3.2.3.1 | Additional Documentation Requests (ADR). | Rev. 13821, June 9, 2026; effective February 26, 2026 |
| 3.2.3.2 | Time Frames for Submission | Rev. 13821, June 9, 2026; effective February 26, 2026 |
| 3.2.3.5 | Acceptable Submission Methods for Responses to ADRs | Rev. 13821, June 9, 2026; effective February 26, 2026 |
| 3.6.4 | Notifying the Provider | Rev. 13821, June 9, 2026; effective February 26, 2026 |
| 3.1 | Introduction | Rev. 13008, December 18, 2024; effective January 17, 2025 |
| 3.2 | Overview of Prepayment and Postpayment Reviews | Rev. 13008, December 18, 2024; effective January 17, 2025 |
| 3.2.1 | Setting Priorities and Targeting Reviews | Rev. 13008, December 18, 2024; effective January 17, 2025 |
| 3.2.2 | Provider Notice | Rev. 13008, December 18, 2024; effective January 17, 2025 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
3.1 Introduction · p. 4
3.2 Overview of Prepayment and Postpayment Reviews · p. 5 · 16 subsections
- Open section 3.2 in the PDF
- 3.2.1 Setting Priorities and Targeting Reviews · p. 7
- 3.2.2 Provider Notice · p. 8
- 3.2.2.1 Maintaining Provider Information · p. 11
- 3.2.3 Requesting Additional Documentation During Prepayment and Postpayment Review · p. 13
- 3.2.3.1 Additional Documentation Requests (ADR). · p. 15
- 3.2.3.2 Time Frames for Submission · p. 16
- 3.2.3.3 Third-Party ADR · p. 17
- 3.2.3.4 ADR Required and Optional Elements · p. 18
- 3.2.3.5 Acceptable Submission Methods for Responses to ADRs · p. 20
- 3.2.3.6 Reimbursing Providers and Health Information Handlers (HIHs) for Additional Documentation · p. 21
- 3.2.3.7 Special Provisions for Lab ADR · p. 23
- 3.2.3.8 No Response or Insufficient Response to ADRs · p. 23
- 3.2.3.9 Reopening Claims with Additional Information or Denied Due to Late or No Submission of Requested Information · p. 25
- 3.2.3.10 Record Retention and Storage · p. 26
- 3.2.4 Use of Claims History Information in Claim Payment Determinations · p. 26
- 3.2.5 Targeted Probe and Educate (TPE) · p. 27
3.3 Policies and Guidelines Applied During Review · p. 31 · 16 subsections
- Open section 3.3 in the PDF
- 3.3.1 Types of Review: Medical Record Review, Non-Medical Record Review and Automated Review · p. 32
- 3.3.1.1 Medical Record Review · p. 32
- 3.3.1.2 Non-Medical Record Review · p. 37
- 3.3.1.3 Automated Reviews · p. 37
- 3.3.2 Medical Review Guidance · p. 38
- 3.3.2.1 Documents on Which to Base a Determination · p. 38
- 3.3.2.1.1 Progress Notes and Templates · p. 39
- 3.3.2.1.2 DMEPOS Orders · p. 41
- 3.3.2.2 Absolute Words and Prerequisite Therapies · p. 41
- 3.3.2.3 Mandatory Policy Provisions · p. 41
- 3.3.2.4 Signature Requirements · p. 42
- 3.3.2.5 Amendments, Corrections and Delayed Entries in Medical Documentation · p. 46
- 3.3.2.6 Psychotherapy Notes · p. 46
- 3.3.2.7 Review Guidelines for Therapy Services · p. 47
- 3.3.2.8 MAC Articles · p. 47
- 3.3.3 Reviewing Claims in the Absence of Policies and Guidelines · p. 49
3.4 Prepayment Review of Claims · p. 49 · 7 subsections
- Open section 3.4 in the PDF
- 3.4.1 Electronic and Paper Claims · p. 51
- 3.4.1.1 Linking LCD and NCD ID Numbers to Edits · p. 51
- 3.4.1.2 Not Otherwise Classified (NOC) Codes · p. 51
- 3.4.1.3 Diagnosis Code Requirements · p. 51
- 3.4.1.4 Prepayment Review of Claims Involving Utilization Parameters · p. 53
- 3.4.1.5 Prepayment Review Edits · p. 53
- 3.4.2 Prepayment Medical Record Review Edits · p. 54
3.5 Postpayment Medical Record Review of Claims · p. 54 · 4 subsections
- Open section 3.5 in the PDF
- 3.5.1 Re-opening Claims · p. 54
- 3.5.2 Case Selection · p. 55
- 3.5.3 CMS Mandated Edits · p. 56
- 3.5.4 Tracking Medicare Contractor's Prepayment and Postpayment Reviews · p. 57
3.6 Determinations Made During Review · p. 57 · 11 subsections
- Open section 3.6 in the PDF
- 3.6.1 Determining Overpayments and Underpayments · p. 58
- 3.6.2 Verifying Errors · p. 59
- 3.6.2.1 Coverage Determinations · p. 60
- 3.6.2.2 Reasonable and Necessary Criteria · p. 60
- 3.6.2.3 Limitation of Liability Determinations · p. 61
- 3.6.2.4 Coding Determinations · p. 62
- 3.6.2.5 Denial Types · p. 63
- 3.6.3 Beneficiary Notification · p. 65
- 3.6.4 Notifying the Provider · p. 66
- 3.6.5 Provider Financial Rebuttal of Findings · p. 69
- 3.6.6 Review Determination Documentation Requirements · p. 70
3.7 Corrective Actions · p. 70 · 11 subsections
- Open section 3.7 in the PDF
- 3.7.1 Progressive Corrective Action (PCA) · p. 71
- 3.7.1.1 Provider Error Rate · p. 72
- 3.7.1.2 Vignettes · p. 73
- 3.7.1.3 Provider Notification and Feedback · p. 74
- 3.7.2 Comparative Billing Reports (CBRs) · p. 75
- 3.7.3 Evaluating the Effectiveness of Corrective Actions · p. 76
- 3.7.3.1 Evaluation of Prepayment Edits · p. 76
- 3.7.3.2 Evaluating Effectiveness of Established Automated Edits · p. 77
- 3.7.3.3 Evaluation of Postpayment Review Effectiveness · p. 78
- 3.7.4 Tracking Appeals · p. 79
- 3.7.5 Corrective Action Reporting Requirements · p. 79
3.8 Administrative Relief from MR During a Disaster · p. 82
3.9 Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings · p. 84 · 2 subsections
- Open section 3.9 in the PDF
- 3.9.1 Election of Status · p. 87
- 3.9.2 Coordination of the ALJ Hearing · p. 91
3.10 Prior Authorization · p. 92 · 3 subsections
- Open section 3.10 in the PDF
- 3.10.1 Prior Authorization Program for Certain DMEPOS · p. 95
- 3.10.1.1 Voluntary Prior Authorization (PA) for DMEPOS Accessories · p. 96
- 3.10.2 Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services · p. 96
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Program Integrity Manual chapter 3
QuickCode supports qualified coder review and documentation clarification before claims are submitted, which is what record reviews test, and QuickRCM keeps record requests, denials and appeals in one workflow with human review.
Frequently asked questions: chapter 3
How long do providers have to answer a Medicare ADR?
Chapter 3 section 3.2.3.2 of the Program Integrity Manual, citing 42 CFR 405.929, gives providers and suppliers 45 calendar days to submit the additional documentation.
How does Targeted Probe and Educate work?
Under section 3.2.5, a MAC reviews a probe sample of typically 20 to 40 claims, educates the provider on the errors found, and repeats the process for up to three rounds. Providers still noncompliant after three rounds are referred to CMS for further action.
What if a medical record signature is missing?
Section 3.3.2.4 allows the reviewer to accept a signature attestation statement or a signature log in certain circumstances; an order or record that cannot be authenticated is treated as unsigned.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Program Integrity Manual, Chapter 3: Verifying Potential Errors and Taking Corrective ActionsVersion Rev. 13821, issued 2026-06-09 · effective 2026-02-26 · file pim83c03.pdfSHA-256 56a2245b712f3b8d…
- Medicare Program Integrity Manual (Pub. 100-08)Version 15 chapter PDFs; newest revision Rev. 13890 (chapter 12), issued 2026-07-30 · effective 2026-09-27 · file 100-08-program-integrity-manual/*.pdf (15 chapters; SHA-256 of their sha256sum listing)SHA-256 efb2c5dd5abb3fe4…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.