Novitas Solutions, Medical Review Part A
2020 Technology Parkway Suite 100
Mechanicsburg PA 17050

ATTENTION: COMPLIANCE OFFICER
Address

ATTENTION: COMPLIANCE OFFICER

Address

Date

RE: Notice of Review - Targeted Probe and Education

Dear Compliance Officer:

In order to fulfill our contractual obligation with the Centers for Medicare & Medicaid Services (CMS), Novitas Solutions, Inc. your Jurisdiction L Medicare Administrative Contractor (MAC), performs reviews in accordance with the CMS instruction. CMS has authorized Jurisdiction L to conduct the Targeted Probe and Educate (TPE) review process. The TPE review process includes three rounds of a prepayment probe review with education. If there are continued high denials after three rounds, Novitas Solutions, Inc. will refer the provider/supplier to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, etc. Note, discontinuation of review may occur at any time if appropriate improvement is achieved during the review process.

This letter serves as notification of the TPE process and to notify you of the initiation of the review. The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations.

Reason for Review

Novitas Solutions, Inc., your Part A Medicare Administrative Contractor (MAC), is tasked with preventing inappropriate Medicare payments which is accomplished through provider education, training, and the medical review of claims. Novitas Solutions, Inc. performs dataanalysis on a regular basis on all providers that it services to assure compliance with the Medicare Program requirements. Based on routine data analysis, Novitas Solutions, Inc. has identified a potential aberrancy with your facility in regard to the billing of IRF - Inpatient Rehabilitation Facility.

Your probe___, which was closed in Month of 20xx had an ___% claim error rate and a ____% dollar error rate. Due to the new Targeted Probe and Educate approach, all reprobes resulting from an initial probe with a moderate or major error classification will be placed in round 2 of the TP&E process. The initial probe will be considered the Round One TP&E probe.

A sample of 20 randomly selected claims are chosen to determine if a provider is billing and coding according to Medicare guidelines and to ensure services are reasonable and medically necessary.

Action: Additional Documentation

Federal law requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. Providers/ suppliers are required to send supporting medical record to Novitas Solutions, Inc. when they are requested. Providing medical records of Medicare patients to Novitas Solutions, Inc. does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request.

If the requested documentation is not returned within 45 days, the claim will be denied due to lack of documentation which will contribute to your error rate. It is your responsibility as a provider to provide the requested documentation within the allotted time frame. Additionally, if providers/suppliers do not respond to the ADR request, MACs have the option to refer to the RAC or ZPIC/UPIC as a result. Novitas Solutions, Inc. will review your claim within 30 days. After all claims selected for the probe are reviewed, you will receive a letter that includes specific findings of our review.

When:

Please do not send any documentation at this time. Your facility will be notified with an Additional Documentation Request (ADR) letter on each claim selected for review. This letter will include a list of specific elements needed to support the service on review. Please ensure the process for routing these documents to the person(s) responsible for submission is timely and effective. Inform your staff responsible for receiving the ADR letters and submitting the required documentation for this review. Authorization for the release of this information is included in Federal Law regulations reference 42 CFR 411.24(a), 424.5(a)(6) and 44 USC 3101.

Instructions once ADR received:

The documentation submitted for this review must be a copy of the patient's medical record for each encounter clearly identified for each requested beneficiary and the date of service. Providers/suppliers are responsible for obtaining supporting documentation from third parties (hospitals, nursing homes, suppliers, etc.).

When submitting medical review records via fax or mail, the DCN specific cover sheet must be placed face up and on top of its corresponding medical documentation.

The ADR will request the following documentation for services rendered:

Submission Methods:

You are responsible for providing documentation for the services identified for the timeframe specified on the Additional Development Request (ADR) which will be mailed to your facility for the beneficiaries that are included in this review. When submitting medical records, the first page of the ADR must be placed face up and on top of its corresponding medical documentation. It would be beneficial if you submit the documentation for all the identified claims at one time to my attention by one of the following methods:

Consequences:

If the requested information has not been received within 45 days of the date on the ADR mailed to your facility, Novitas Solutions, Inc. will initiate claim adjustments or overpayment recoupment actions for these undocumented services.

Education:

Upon completion of the claim sample, the nurse reviewer will contact you to schedule a 1:1 educational session regarding any errors noted during the claim review. Novitas Solutions Inc. offers webinars, which are web-based presentations using internet technology. If your office does not have internet capabilities, a traditional teleconference will be offered. We can offer other methods of direct communication if these methods are not convenient. Medical Review will also provide you written notification at the end of the review to include your results. This letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part and limited education on the results.

In Closing:

Thank you for your participation with this review. Please contact ____ referencing the case number above upon receipt of this letter to provide the name of a contact person, if not already communicated, or with any questions regarding the information in this letter.

Questions:

If you have any additional questions regarding this request, please contact me at or via postal mail at the following:

Sincerely,

Clinical Reviewer
MAC Jurisdiction JL
Medical Reviewer Part A
Novitas Solutions, Inc.

cc: Dr. Patterson, Vice President & Contract Medical Director
Dr. Hayes, Contract Medical Director

enc: 1) Novitas Portal Information (Novitasphere)

2) Documentation Checklist

3) TPE Process Flowchart

Enroll in Novitasphere today!

Once enrolled - Ready, Set, GO!

Checklist: Inpatient Rehabilitation Facility (IRF) Documentation

This checklist is intended to provide Healthcare providers with a reference for use when responding to Medical Documentation Requests for Inpatient Rehabilitation Facility (IRF) services. Healthcare Providers retain responsibility to submit complete and accurate documentation.