Medical Review Targeted Probe and Educate Additional Development Requests

CMS’ TPE program is provider specific education that will focus on improving issues without allowing other problems to develop along with an opportunity for the provider to ask questions.

TPE reviews include processed (post-payment) and new claim(s) submissions (pre-payment).

NGS MR will contact providers being audited.

TPE reviews include up to three rounds. If the providers error rate remains high upon completion of first round, provider is retained for second and, potentially, third round of reviews.

Respond to ADRs within 35-40 days of letter date (CMS allows providers 45 days of the ADR date) and all services must include necessary signatures and credentials of professionals. Medical review documents, medical records, and responses to ADR letters may be sent electronically or by mail.

TPE’s include notification letters followed by separate ADRs for each claim involved.

The notification letter for post-payment TPE reviews will list all the claims being selected for review.

The ADRs are computer generated letters requesting additional information.

Be aware, medical review ADRs will state “Claim Medical Review Department” in the salutation.