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Medical Review - Novitas Probe and Educate Questions and Answers
Targeted Probe and Educate Questions and Answers
What is Targeted Probe and Educate (TPE)?
Novitas has initiated Targeted Probe and Educate under the direction of CMS to reduce provider burden.
The TPE process will consist of three rounds of prepayment (or post payment) probe reviews with one-on-one education and provides Novitas the opportunity to educate providers before, during and after the probe.
Providers will receive initial notification education before Additional Documentation Requests (ADRs) are sent out to help them understand the documentation requirements for the procedure code involved with the review and how to properly submit the documentation. Education will continue during the probe and additional documentation may be requested if resolvable errors are found while completing the review. At the end of the probe the reviewer will offer an educational teleconference to provide detailed one-on-one education on errors found during the probe.
Providers who result in a minor error rate will not move on to the next round of TPE. Providers who result in a moderate or major error rate will move on to the next round and will receive additional education.
There is a 45 day break between each probe round, giving providers time to implement any changes they feel are necessary after education.
How do providers get selected for TPE?
Novitas will select topics for review based on current data analysis, the most egregious providers identified during the data analysis will be selected for TPE to validate the services billed to Medicare The procedures are outlined in
CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2
What notification will providers receive?
Novitas will notify providers who have been selected for review with an initial notification letter which will include the topic being reviewed, the reasons for selection which will be supported by data analysis, and the process of review. The nurse reviewer will also call the provider to establish a contact person, introduce their self and provide initial education and information.
How will the provider get the Additional Documentation Requests (ADRs)?
ADRs are mailed to the address listed in the standard system (FISS / MCS).
providers may also print / view the ADRs in FISS.
Access the claim Summary Inquiry Screen in FISS (selection 12 on the Inquiry Menu) type a Provider Number or Medicare Beneficiary ID Number and press enter. If the Status / Location is S B6000-B6001 there is an ADR on this claim.
Type the selection code “S” in the left hand column of the screen in the SEL field. Press Enter. Go to page 06, hit PF8 to view / print the ADR. Submit the printed ADR letter along with the documentation.
How do providers change the address in the standard system (FISS / MCS)?
Providers may change the address listed in FISS / MCS by filling out a CMS-855 Form.
Click on the link for step by step assistance filling out the
You may also contact Customer Contact Center for assistance:
JL Provider Contact Center 1-8877-235-8073
JH Provider Contact Center 1-855-252-8782
How do providers prepare documentation for submission?
The Initial Notification Letter includes a documentation checklist to help providers prepare documentation for submission. The documentation checklist can also be found on the Novitas website under Medical Review, Targeted Probe and Educate. The ADR also lists the required documentation.
Click the link for sample initial notification letters (Part A only). (
Click the link for additional documentation checklists. (Part A:
) (Part B:
Novitas Solutions accepts medical records via:
Electronic Submission of Medical Documentation (esMD)
CD / DVD
Once an ADR is received a provider should do the following:
Collect all requested documentation
Verify all documentation requested is included in your submission
Attach the first page of the original ADR request as the cover sheet to the records
If you are responding to multiple MR ADR requests, clearly separate the documentation for each claim by inserting the first page for each ADR letter separately for the applicable documentation that pertains to that ADR letter. Multiple responses sent together, but not separated, may result in the documentation being imaged as one claim or claim may be rejected completely.
For more information including mailing addresses, please click
How do providers get education?
One-on-one education will be offered directly to the providers selected throughout the TPE process.
Pre-education will begin before ADRs are sent. The provider will receive an initial notification letter with the reason they were selected, a documentation checklist, and contact information for the reviewer assigned to the probe. The nurse reviewer will also reach out the provider to establish a contact person and provide education.
Intra-education will occur during the probe. The reviewer will reach out to the provider for intra-probe education when necessary.
Post-education will be provided once the probe has been completed; a Review Results Letter will be mailed to the provider with a detail report of the claim by claim review findings. An educational teleconference will be offered to any provider receiving a moderate or major error classification.
The Novitas website will also post all applicable education links.
Does each topic for review have an end date?
There is no specific end date as it will be determined on the length of time for ADRs to be sent. Typically the end date will be 3-4 months following the start date.
We have received ADRs for topics other than the notice of review for TPE letters. What is the difference?
Part A does have four Low Volume Targeted Probe and Educate edits. The list for
can be found on the Novitas-Solutions website. If any claims included in the edits are denied an educational call will be provided.
Will the TPE sampling start based on the date of service or the submission date?
The TPE sampling start is based on the submission date.
Is there a sample of the initial letter?
Sample letters for each Part A TPE topic can be found on the
Please use the links below for the initial letter sample for each topic and region.
90999 End Stage Renal Disease (ESRD)
E41 and E43 Severe Malnutrition
J0897 Denosumab (Prolia/Xgeva)
Cardiovascular Nuclear Medicine
Skilled Nursing Facility (SNF)
Inpatient Rehabilitation Facility (IRF)
How does Novitas determine the difference between a minor, moderate, or major error rate classification?
The error percentage that qualifies a provider/supplier as having a minor, moderate or major classification rate varies based on the service/item/topic under review. It is important to note that the determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round, with education being provided during and after each round in order to help the provider/supplier throughout the process.
What if I do not agree with Novitas' determination? Does the TPE process change the current appeal process in place for Medicare providers?
The process for appealing claim determinations remains the same. For specific information related to the appeals process, please visit our Appeals Center (
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