Targeted Probe and Educate Resumed September 1, 2021

Published 08/31/2021

The Targeted Probe and Educate (TPE) process will be resumed effective September 1, 2021. Please refer to the Active Medical Reviews article for a list of review topics. All service-specific reviews will be phased out. Please also refer to MLN Connects: article, "CMS Resumes Targeted Probe and Educate," August 12, 2021.

Palmetto GBA may select providers for the TPE process based on, but not limited to, the reasons listed below. TPE cases that remained open during the Public Health Emergency (PHE) have been closed. For additional information about provider selection please refer to CMS IOM Publication 100-08, Chapter 3 (PDF, 652 KB), Section 3.2.5.B.

  • Analysis of billing data indicating aberrancies; or
  • On targeted review and is transitioned to the TPE process based on error rate results; or
  • On service specific review error rate results

Palmetto GBA will send a notification letter to providers as identified that have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information. Please see additional overview of TPE process below. You may also refer to CMS IOM Publication 100-08, Chapter 3 (PDF, 652 KB), Section 3.2.5 for additional details about TPE.

  • TPE consists of up to three rounds of review with a 20–40 claim sample selected (pre-payment or postpayment) for each round
  • In addition to the provider notification letter described above, an Additional Document Request (ADR) will be generated for each claim selected 
    • For pre-pay reviews, Palmetto GBA will conduct the review within 30 days from the date the documentation is received and make a payment decision
    • For postpay reviews, Palmetto GBA will conduct the review within 60 days from the date the documentation is received and make a payment decision
    • Please provide the documentation requested in the ADR within 45 days of the date of the ADR 
  • Medicare contractors do have the discretion to grant an extension to providers who need more time to comply with the medical record request due to hardship. If you are unable to reply within the required timeframe due to hardship, please submit an extension request outlining your hardship to Palmetto GBA using your preferred submission method. Please be aware that this instruction is specific to restarting TPE and is intended to be temporary in nature; the ability to request an extension will coincide with the COVID 19 Public Health Emergency. Please include the required information with your extension request, addressed to MR TPE ADR Extension Request:
    • The identifying claim information (date of service, claim number, beneficiary name and MBI)
    • The identifying provider information (provider number, provider name and name of requestor)
  • If the provider fails to send the requested documentation or request an extension within 45 days, the review determination will be to deny the claim as not reasonable and necessary as per the Social Security Act, Sections 1815(a), 1833(e), and 1862(a)(1)(A) 
    • Non-Response denials count as an error when calculating the probe error rate
  • Palmetto GBA reviewers will contact the provider by phone to request additional documentation for any easily curable errors identified that can be resolved during the review process
    • Please make sure to include a point of contact (POC) with the response to the ADR for these potential calls
  • Palmetto GBA will contact the provider at the conclusion of each probe round to offer a one-on-one educational session
  • A minimum of 45 days will be allowed after each post-probe educational session before selecting new claims if a subsequent probe is required 
  • At the conclusion of each probe round for the 20–40 claims selected for review, a results letter with the review results for that probe will be sent. The letter will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part and associated education.
    • Providers will also receive an education letter at the conclusion of each reviewed claim
  • If high denial rates continue after three rounds of TPE, Palmetto GBA will send a referral to CMS for additional action 


Submission Methods

Providers may submit this documentation in any of the following ways:

eServices

  • Visit our website for more information

Electronic Submission of Medical Documentation (esMD)

  • Include a copy of the ADR with your documents
  • More information on esMD can be found on the CMS website

Fax

  • Include a copy of the ADR with your documents
  • Please refer to the Contact Me tab for your jurisdiction for the fax number

U.S. Mail

  • Include a copy of the ADR with your documents
  • Please refer to the Contact Me tab for your jurisdiction for the fax number


Resources

  • CMS Publication 100-08, Chapter 3 (PDF, 652 KB), Section 3.2.5
  • MLN Connects: CMS Resumes Targeted Probe and Educate, August 12, 2021