Best Practices for a Successful Targeted Probe and Educate Review

Table of Contents

• Getting Started With TPE
• Notification Letter
• During the Review Process
• Post-Probe/Review Results Letter
• Prepare for Post-Probe Education

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Getting Started With TPE:

• Use NGSMedicare.com to your advantage!
  • You can learn about the TPE correspondence headed your way here: Targeted Probe and Educate Letters - An Informational Overview
  • You may learn about current review topics, denial trends and utilize a number of helpful resources.
• Ensure that your address in PECOS is accurate for all mailed communications. See instructions on how to change your address.
• Learn how to Find and Respond to a TPE ADR here.
• Utilize NGSConnex when responding to an ADR. The NGSConnex User Guide provides step-by-step instructions on how to complete numerous tasks with the web-based platform. NGSConnex allows you to obtain beneficiary eligibility information, initiate and check the status of redetermination and reopening requests, and query the status of your claim, among many additional free and secure tasks.

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Notification Letter:

• Respond to the notification letter with a point of contact so the Medical Review team may reach out with questions and to resolve easily curable errors through intra probe education.
  • Sharing a phone number and email will increase the likelihood of a successful intra probe call, when needed, as well as expedite post probe education scheduling.
• Best practice suggestion: Initiate internal dialogue with your patient care team, compliance, billing, etc. to ensure all pertinent departments are involved and aware of the review.

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During the Review Process:

• Ask questions during the review process, don't wait for the post-probe education!
  • You may contact the CMT via e-mail for any TPE or Medical Review questions:
    • JKACaseManagement@ElevanceHealth.com
    • J6ACaseManagement@ElevanceHealth.com
    • JKBCaseManagement@ElevanceHealth.com
    • J6BCaseManagement@ElevanceHealth.com
  • You may contact the Provider Contact Center with questions regarding:
    • The reason a claim was processed as it did
    • Assist with general Medicare information/billing questions
    • Provide guidance on how to use the IVR system and the NGSMedicare.com website
    • Assist with other complex issues that cannot be addressed through the IVR system
• Reach out early if you are seeing denied claims and you are unaware of the reason, for example: a treatment plan is noted as missing and you believe you sent one in for review, so you may remedy this before all claims have been requested, reviewed and processed.

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Post-Probe/Review Results Letter:

• We encourage you to reach out within seven days of receipt of the Results Letter to schedule education. Use the appropriate CMT address above if you have not received your letter, as we are able to ensure you receive this letter and schedule education accordingly.
  • This will ensure you receive education catered to your needs, and adequate time to identify areas for improvement and implement appropriate process changes.
• If you decline education, or do not reach out to schedule education, you will be moved to the next round of review, which may start 45 days from the date on your Results Letter.

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Prepare for Post-Probe Education:

• Monitor your appeal deadline—Do not wait for education to submit your appeals. If you disagree with a decision, or have additional supporting documentation for a denied claim, please ensure you are submitting an appeal timely. Do not wait for the Results letter to submit an appeal.
  • Click here to learn About Appeals.
  • Ensure appropriate staff are available for the educational call.
  • Share the Results Letter and corresponding spreadsheet with appropriate staff to ensure the team is prepared for the call and can receive answers to their questions.
  • Read the entire reason statement/rationale for your denied claims to appropriately address all denied elements upon appeal if you choose to proceed with an appeal.
  • If you experience challenges, please reach out to the CMT email addresses listed above. We can help you!

Reviewed 6/20/2024