Targeted Probe and Educate Letters – An Informational Overview

As part of our contractual obligation with the CMS, NGS, your Jurisdiction 6 or K MAC performs TPE to analyze provider compliance with CMS regulatory requirements. The TPE review process includes up to three rounds of a claim review with opportunities for education throughout the process. During this process, you will receive communications in the form of letters: The notification letter, ADR letters, claim RA, and a results letter.

Notification Letter

The first letter a provider receives when they begin the TPE process is the Notification letter which is enclosed in a pink envelope. This letter outlines why you have been selected for review as well as what to expect throughout the review and education process. View a sample TPE notification letter for additional details.

Some TPE reviews involve claims that have already been processed (post-payment). The notification letter for post-payment TPE reviews will include a listing of all the claims being selected. TPE reviews that are being done for new claim submissions (prepayment), will include a notification letter followed by separate ADRs for each claim involved.

Please provide contact information for any personnel who will be handling TPE claims and education, to the email address provided in the letter.

ADR Letters

When a claim is selected for review, an ADR letter is generated requesting medical documentation. These letters are mailed to either the “Pay To” or “Practice Location” address that you have designated on your enrollment application to NGS. To ensure payment is appropriate and supports the submitted charges, please ensure that this ADR letter is received by the appropriate person within your organization so that a timely and complete response is submitted. Processes should be established to ensure that proper staff is receiving and responding to ADRs in a timely fashion to avoid denials due to nonresponse.

You must respond to ADRs prior to the 45 day deadline (based on the date of the ADR) for each claim selected. Providers are highly encouraged to respond to the ADR by sending all applicable medical records prior to day 45. To calculate the response time for your ADR letter, visit the Additional Development/Documentation Request Timeline Calculator.

Each ADR letter includes all of the details you need to respond to the medical record request. The following information is contained in each ADR letter:

The contractor requesting the medical records.
The claim for which medical records are required.
The reason for the medical record request.
The medical records that are being requested.
The date that the records must be received by.
Where to send the records.
How to submit the records.

Examples of medical documentation includes but is not limited to; certificates of medical necessity, clinical evaluations, consultations, home health records, hospital records, imaging reports, physician orders, etc. For additional documentation examples, visit the Additional Development Request Letters Guide. The ADR letter will offer various methods of submitting records, such as through NGSConnex (recommended).

You have the ability to check the status of ADRs that have been responded to by anyone within your provider organization regardless of the method of response through NGSConnex. Here you will find the ADR letter text, claims selected for review, and other ADR details. NGS is committed to supporting ongoing improvements to NGSConnex. Visit the NGSConnex User Guide for instructions on how to check the status of ADRs.

Remittance Advice and Results Letter

NGS has 30 to 60 days from the date the documentation is received to review the documentation and make a payment determination. At the conclusion of each round of medical review, you will receive a Results Letter with your results from the TPE review. This letter will contain the number of claims that were reviewed, the number of claims that were denied, and the error rate.

For our Part A providers, included in the letter will be instructions on how to find the denial reasons on page 4 of the Fiscal Intermediary Standard System Direct Data Entry System. Follow up action instructions will be detailed in the results letter. In addition, the case management email address you will utilize to set up contact for your TPE will be in the results letter. It is strongly encouraged that you schedule the TPE educational session by responding to the instructions in the results letter. If your error rate is over 15% and you do not seek education, it will be marked as a refusal.

Depending upon the results of each round of review, you may be moved to an additional round of TPE review for up to three rounds of review. MACs may begin sending documentation requests for claims with dates of service no earlier than 45 days after the previous post-probe one-on-one education. This gives you the opportunity to make changes based on the education received prior to being subjected to additional review. If a provider declines to schedule education within a reasonable time after receiving the offer, subsequent reviews will be for claims with dates of service no earlier than 45 days from the one-on-one post-probe education offer.

It’s important to note results letters are only sent out at the end of the TPE rounds and after all claims have been processed. In the meantime, you may receive a RA prior to the results letter. Please do not wait for the results letter to file an appeal. The appeals timeline starts when the RA is sent. To exercise your right to an appeal, you must file a request in writing within 120 days from the date of the initial decision on the claim. Refer to the NGS website for information about the appeals process.

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Published 7/29/2022

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