Results Letters

After National Government Services reviews the requested claims for your facility/office, you’ll receive a Results Letter with results from that round of TPE review. The Results Letter will contain the number of claims that were reviewed, the number of claims that were denied, the CER, and the charges/PER In addition, the Results Letter will list all the claims in the round of review, the review decision for each claim, and the denial reason code for each denied claim.

Each denied claim has a denial rationale/narrative from the clinical reviewer with additional details about the denial. All denial rationales can be found in the FISS DDE Provider Online Guide on page 04. If the claim was submitted through NGSConnex, the denial narrative can be found on the Medical Review ADR Details screen under Additional Review Information.

If your PER is over 15%, you will proceed to the next round. If you are proceeding, you are strongly encouraged to schedule a TPE educational session with our Care Management Team. The Results Letter will include an email address you may utilize to set up this session. If your PER is over 15% and you do not contact case management for education, it will be marked as a refusal of education.

You may file an appeal before receiving the Results Letter. The appeals timeline starts when the claim has finalized in the system, and you have received your RA. The time limit for filing an appeal for redetermination is 120 days from the date of receipt of the RA. Please reference the appeals material on our website for additional information on the appeals process.

Results Letters

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