Sample Results Letter

MAIL DATE

PROVIDER NAME
PROVIDER ADDRESS
CITY, STATE, ZIP

Provider PTAN/NPI Number: XXXXXXXX

RE:Notice of Review - Targeted Probe and Education Results (Round X)

Case Number: XXXXXX

Dear Medicare Provider, Supplier or Compliance Officer,

As part of our contractual obligation with the Centers for Medicare & Medicaid Services (CMS), National Government Services, Inc., your Jurisdiction 6 or K Medicare Administrative Contractor (MAC), performs Medical Review to analyze provider compliance in accordance with the CMS instruction. Medical Review initiated a Targeted Probe and Educate (TPE) review of X services on month/day/year. This letter is to notify you of the results for round X of your TPE review. Thank you for your cooperation during this prepayment audit.

This letter includes a summary of the results of this review, our review findings and follow-up actions.

RESULTS

The following is a summary of the claims reviewed.

FINDINGS/FEEDBACK

You may also refer to page 4 using your DDE RA and the attached claim detail spreadsheet to determine your claim specific denial reasons. Claims denied due to “No Documentation Received” (denial code 56900/692) will be counted towards the results unless NGS issued the provider an extension.

FOLLOW-UP ACTIONS

The review of claims sampled for round X of the TPE process has been completed. Based on the findings, it has been determined that you/your facility will proceed to round X of the TPE process. As a result, NGS encourages you/your facility to contact J6Bprobeandeducate@anthem.com or JKBProbe&Educate@anthem.com upon receipt of this letter to register for one-on-one provider education. During this individualized education session, we will discuss claims/denials you have received, as well as answer any questions your facility may have regarding the policy or the TPE process. If you choose not to reach out for education within 2 weeks of the date of this letter, this will be tracked as a refused offer.

DIRECTIONS FOR REQUESTING 1:1 PROVIDER TELEPHONIC EDUCATION

All requests for 1:1 telephonic education on this review should be directed to J6Bprobeandeducate@anthem.com or JKBProbe&Educate@anthem.com DO NOT SEND PHI or PII to this mailbox. A proper request for education should include in the subject line “Request for Education Case#, PTAN/NPI#“. In the body of the email, please include contact name, telephone number where the listed contact can be reached, fax number and a brief statement to identify your case. During the education session, please have the attached detailed claim listing available to refer to.

Please note that the purpose of the TPE process is to identify areas of confusion and to address these areas through education, supporting providers in their goal of submitting claims that are in compliance with Medicare policy.

If you are interested in appealing the individual claim decisions, please refer to the remittance advice to calculate the deadline for each claim. DO NOT WAIT for education prior to appealing. This education is not a forum for appeal. See www.ngsmedicare.com, under the Appeal tab for instructions and Medicare Learning Network Article 9974.

If you would like additional education on topics outside the scope of this letter, please contact the PCC Inquiry Line to request a referral to POE. Please note that POE is not able to address specific claim denials.

The NGS website (www.ngsmedicare.com) contains educational materials. Use the website information and any enclosed materials in efforts toward education of your staff and quality improvement. Please visit the Centers for Medicare and Medicaid Services website (www.cms.gov) for additional helpful information.

Important Reminder: Written inquiries sent by e-mail cannot contain any Protected Health Information (PHI) or Beneficiary specific information as this risks violation of the HIPAA. You must include your provider number, provider name and a point of contact with a telephone number to assist with obtaining a response. Per the IOM 100-09 Medicare Contractor Beneficiary and Provider Communications Manual – Chapter 6, Section 30.3 – Provider Written Inquiries.

We remind you that submission of these records is fully compliant with HIPAA. All Medicare claim forms include a beneficiary authorization for providers to release requested medical records to the processing contractor.

Thank you kindly for your time and attention to the information in this letter.

Sincerely,

National Government Services, Inc.