Medical Review

Targeted Probe and Educate Strategy and the NGS Medical Review Process

As directed by CMS, effective 10/1/2017, NGS Medical Review will transition all lines of business to a Targeted Probe and Educate (TPE) strategy. The purpose of this transition is to reduce costs related to improper payments and appeals, therefore reducing provider burden. Home health and SNF demand bill review are CMS mandated reviews and will not transition to TPE.

Providers selected for TPE will receive a notification letter from us (enclosed in a pink envelope) via USPS or fax. The notification letter will provide details about TPE, it will also include our educational email address that providers should use to schedule education. In addition, something new that Medical Review is doing for TPE, we are asking providers to notify us using the shared mail box, of a delegated contact associate from their facility who could answer any questions we may have regarding their TPE review, requests for additional information and serve as a contact name for our TPE correspondence. Providers are requested to submit the contact information to our shared email address and include the contact name, provider name, provider number, email address, and phone number.

Responding to TPE ADRs

In order to avoid claim processing delays it is important that providers respond to ADR in a complete and timely manner. Listed below are guidelines and checklists that will provide assistance in submitting claims: 

1. NGS recommends responding to ADRs within 35-40 days of letter date (CMS allows providers 45 days of the ADR date) See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
2. Be sure to forward the requested documentation to the correct NGS post office box.
3. Send each response separately and attach a copy of the corresponding ADR. It is acceptable to send multiple responses in a single mailing; however, each response must be individually bundled with a copy of the corresponding ADR within the mailing to facilitate proper handling and review of the ADR response.
4. Include all records necessary to support the services for the dates requested.
5. Do not include additional correspondence with documentation submissions. Unrelated correspondence should be mailed separately.
6. Records must be complete and legible. Be sure to include both sides of double-sided documents.
7. The NGS self-service portal, NGSConnex, allows both Part A (including home health, hospice and FQHCs) and Part B providers to respond to ADRs electronically with no need to mail or fax a response to complete the ADR process. Further details are available on our website. If you are a current user of NGSConnex, click on the link for a new NGSConnex User Guide for step-by-step instructions on how to submit ADR. If you are not a current user, sign up and get started!
8. All services must include necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, “Signature Requirements”. (KB 592)

Part A providers only: Steps to View and Print ADRs from FISS/DDE Provider Online System

1. Access the claims through the Claims Inquiry screen/option
2. Type 01 at the FISS/DDE Online System Main Menu and then type 12 on the Inquiry Menu for claims
3. At the Claims Inquiry screen, type SB6001 in the S/LOC field and press <Enter> - all claims in the SB6001 status and location will be displayed (SB6001 status indicates that an ADR has been generated for a claim)
4. At the desired claim, type S to the left of the claim under the SEL field and press <Enter>
5. The ADR letter follows claim page 06 of the claim
6. The online ADR letter consists of two pages; to view the second page, press the <P8>/<PF8> key to move forward to the next page
7. Please be sure to not press the <P9>/<PF9> key while viewing a claim in the SB6001 status—this will cause the claim to recycle and generate a second ADR letter

Note: If using the ADR printed from the FISS/DDE Provider Online System, the copies of requested records are due to NGS 30 days from the date the claim went to S/LOC SB6001 in FISS/DDE.

Prepayment Decision Timeline

The MAC will make and document review determinations within 30 calendar days of receiving the provider’s requested documentation.

Postpayment Probes

On rare occasions, MR may conduct postpayment claim reviews. In the postpayment probe process, a sample of paid claims is selected and MR requests records from the provider in a letter that summarizes the probe process and includes a list of specific claims for which the provider must copy and submit medical records to support the service.

Providers must submit medical records as directed by the MR notice letter within 45 days of the record request. In certain circumstances, an extension may be granted on this timeframe, through contact with the reviewer who initiated the request.

Reopenings for Untimely Submission of Medical Records

The Medical Review department has the discretion to reopen a claim that was denied due to untimely submission of requested information.If the requested documentation for the denied claim is received within 120 days of the denial, MR will reopen the claim. The submitted late documentation will be reviewed, and an adjustment will be subsequently issued that will reflect the outcome of the MR determination. A new Medicare Summary Notice (MSN) and remittance advice for the adjusted claim will be generated to provide revised determination and appeals information.

Late documentation can be submitted through one of the following ways:

• Submit late documentation as directed in the additional development/documentation request (ADR) letter, e.g., mailing address or fax number.
• Through the NGS self-service portal, NGSConnex. Further details on how to respond to ADR are available on our website.
• Submit an appeal.

For reopening request received thru an appeal, provider will be notified of Medical Review's intent to reopen the late claim. This notification will be received through one of the following mechanisms: telephone contact, by letter, fax or email.

Targeted Probe and Educate Strategy and the NGS Medical Review Process

As directed by CMS, effective 10/1/2017, NGS Medical Review will transition all lines of business to a Targeted Probe and Educate (TPE) strategy. The purpose of this transition is to reduce costs related to improper payments and appeals, therefore reducing provider burden. Home health and SNF demand bill review are CMS mandated reviews and will not transition to TPE.

Providers selected for TPE will receive a notification letter from us (enclosed in a pink envelope) via USPS or fax. The notification letter will provide details about TPE, it will also include our educational email address that providers should use to schedule education. In addition, something new that Medical Review is doing for TPE, we are asking providers to notify us using the shared mail box, of a delegated contact associate from their facility who could answer any questions we may have regarding their TPE review, requests for additional information and serve as a contact name for our TPE correspondence. Providers are requested to submit the contact information to our shared email address and include the contact name, provider name, provider number, email address, and phone number.

Responding to TPE ADRs

In order to avoid claim processing delays it is important that providers respond to ADR in a complete and timely manner. Listed below are guidelines and checklists that will provide assistance in submitting claims: 

1. NGS recommends responding to ADRs within 35-40 days of letter date (CMS allows providers 45 days of the ADR date) See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
2. Be sure to forward the requested documentation to the correct NGS post office box.
3. Send each response separately and attach a copy of the corresponding ADR. It is acceptable to send multiple responses in a single mailing; however, each response must be individually bundled with a copy of the corresponding ADR within the mailing to facilitate proper handling and review of the ADR response.
4. Include all records necessary to support the services for the dates requested.
5. Do not include additional correspondence with documentation submissions. Unrelated correspondence should be mailed separately.
6. Records must be complete and legible. Be sure to include both sides of double-sided documents.
7. The NGS self-service portal, NGSConnex, allows both Part A (including home health, hospice and FQHCs) and Part B providers to respond to ADRs electronically with no need to mail or fax a response to complete the ADR process. Further details are available on our website. If you are a current user of NGSConnex, click on the link for a new NGSConnex User Guide for step-by-step instructions on how to submit ADR. If you are not a current user, sign up and get started!
8. All services must include necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, “Signature Requirements”. (KB 592)

Prepayment Decision Timeline

The MAC will make and document review determinations within 30 calendar days of receiving the provider’s requested documentation.

Postpayment Probes

On rare occasions, MR may conduct postpayment claim reviews. In the postpayment probe process, a sample of paid claims is selected and MR requests records from the provider in a letter that summarizes the probe process and includes a list of specific claims for which the provider must copy and submit medical records to support the service.

Providers must submit medical records as directed by the MR notice letter within 45 days of the record request. In certain circumstances, an extension may be granted on this timeframe, through contact with the reviewer who initiated the request.

Reopenings for Untimely Submission of Medical Records

The Medical Review department has the discretion to reopen a claim that was denied due to untimely submission of requested information.If the requested documentation for the denied claim is received within 120 days of the denial, MR will reopen the claim. The submitted late documentation will be reviewed, and an adjustment will be subsequently issued that will reflect the outcome of the MR determination. A new Medicare Summary Notice (MSN) and remittance advice for the adjusted claim will be generated to provide revised determination and appeals information.

Late documentation can be submitted through one of the following ways:

• Submit late documentation as directed in the additional development/documentation request (ADR) letter, e.g., mailing address or fax number.
• Through the NGS self-service portal, NGSConnex. Further details on how to respond to ADR are available on our website.
• Submit an appeal.

For reopening request received thru an appeal, provider will be notified of Medical Review's intent to reopen the late claim. This notification will be received through one of the following mechanisms: telephone contact, by letter, fax or email.