Applicable to Jurisdiction L - which spans Pennsylvania, New Jersey, Maryland, Delaware and the Washington D.C. Metro Area (Arlington and Fairfax counties in Virginia, the city of Alexandria, VA, the District of Columbia, and Montgomery and Prince George’s counties in Maryland)
Targeted Probe and Educate Questions and Answers
For additional information on specific Targeted Probe and Educate topics, education and results please review the links below:
Targeted Probe and Educate (TPE) is one process that a Medicare Administrative Contractor (MAC) can utilize when providers are selected by Medical Review. The TPE review process includes three rounds of a prepayment probe review with education. If there are continued high denials after the first three rounds of reviews, Novitas will refer the provider and results to the Center for Medicare and Medicaid Services (CMS). CMS will determine additional action, which may include extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the Recovery Auditor (RA) contractor, etc.
Note: Discontinuation of review may occur at any time if appropriate improvement is achieved during the review process.
The key elements of this probe and educate include:
If selected for a TPE review, providers are not excluded from other Medical Review activities such as automated reviews, comparative billing reports, mandated demand bill reviews, other pilot review strategies, etc. as directed by CMS or other contractor reviews. Additionally, Novitas will continue to work with other CMS contractors and collaborate with referrals back and forth to the Quality Integrity Organization (QIO) for quality of care concerns, the ZPIC/UPIC for concerns related to potential fraud and/or abuse, and the RA contractor to ensure there is no duplication of reviews.
An example of the Additional Development Request that will be received related to TPE is linked below:
Do you have additional questions? If so, please review our Targeted Probe and Educate Questions and Answers or Email a Question about Medical Review Part A to Novitas Solutions.