What are the three review processes RACs follow to identify improper payments?

• A. Prepayment review, Postpayment review, and Reconciling review
• B. Data mining, Field audit, On-site audit
• C. Automated review, Semi-automated review, and Complex review
• D. Manual review, Telephonic review, On-site review

Answer: (C)

RACs identify improper payments using a three-tier review approach: automated review, semi-automated review, and complex review.

Automated review is the first pass, using rules and data analytics to flag claims that clearly violate policy or contain straightforward errors (such as mismatches, duplicates, or obvious overpayments). This lets a large volume of claims be screened quickly without human review.

Semi-automated review adds human judgment to the automated flags. Reviewers examine the claims that automated systems flagged, apply clinical or policy nuance, verify supporting documentation, and decide whether the payment is improper based on context that automation can’t fully capture.

Complex review is the most in-depth step, reserved for high-risk or high-dollar cases. This involves thorough manual audit work, detailed file reviews, and sometimes cross-record verification to determine improper payments that require comprehensive analysis and documentation.

This three-tier structure is the standard RAC workflow because it efficiently screens vast claim data, applies judgment where needed, and reserves intensive resources for the most significant cases. The other groupings describe different activities or audit types that aren’t the RAC three-tier review framework.