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Printed Date: 9/22/2015
Change Request 10249 (PDF, 241 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. Based on data analysis of claims payment, Palmetto GBA will identify areas with the greatest risk of inappropriate program payment. Refer to the Active Medical Reviews article for a list of review topics. All service-specific reviews will be phased out.
Palmetto GBA selects providers for the TPE process based on the following:
Palmetto GBA will mail a letter to those who 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.
Note: Non-response denials count as an error when calculating the error rate. Palmetto GBA recommends using eServices, our secure online web portal to submit documentation in response to medical review ADRs and when/if additional documentation is requested throughout the review process. You may refer to the eServices User Manual (PDF, 7.83 MB) for instructions. If you are not already registered to use eServices, refer to Registration on page 17.
Prior to the conclusion of each round, the medical reviewer will call all providers with moderate to high error rate to discuss the summary of the errors found.
At the conclusion of each round, a letter with the review results will be mailed. 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.
When high denial rates continue after three rounds of TPE, Palmetto GBA will send a referral to CMS for additional action.
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Last Updated: 02/07/2018