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Targeted Probe and Educate (TPE) Process

Change Request 10249External PDF implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017.  Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment. Refer to the  All service-specific reviews and targeted provider specific will be phased out.  

 

Key Points

 

·         CGS selects providers for the TPE process based on the following:

o   Analysis of billing data indicating aberrancies that may suggest questionable billing practices; or

o   On targeted review and is transitioned to the TPE process based on error rate results; or

o   On service specific review error rate results.

 

·         CGS 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.

 

·         TPE consists of up to three rounds of review with up to 20-40 claims selected (pre or post payment) with each round.  Subsequent rounds will begin 45-56 days after individual provider education is completed.  Discontinuation of review may occur if appropriate improvement and error rate below the target threshold is achieved during the review process.

 

·         An Additional Documentation Request (ADR) will be generated for each claim selected.  CGS has 30 days from the date the documentation is received to review the documentation, and make a payment decision.

 

Note: No response to ADRs (denial reason 56900) count as an error when calculating the error rate.  CGS recommends using myCGS, our secure online web portal to submit documentation in response to medical review ADRs.  For additional information, refer to the myCGS User Manual Part A Chapter 7: Forms TabPDF for instructions.

 

If you are not already registered to use myCGS, refer to the enrollment instructions found in Chapter 1 of the myCGS® User ManualPDF.

 

·         A letter with the review results will be mailed at the conclusion of each round.  The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.   

 

·         Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered.  CGS offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Providers may also submit questions or request education via the Part B TPE email box at J15AprobeandEducation@cgsadmin.com .

 

·         When high denial rates continue after 3 rounds of TPE, CGS will send a referral to CMS for additional action. 

 

Resources:

·         Change Request 10249External Website

·         Targeted Probe and Educate Frequently Asked Questions

·         CMS Publication 100-02, Medicare Benefit Policy ManualExternal Website

·         Additional Documentation Requests (ADRs): What to Send




Posted: 10.02.17

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