License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
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Top Provider Questions - Targeted Probe and Educate

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What is Targeted Probe and Educate (TPE)?
- As a Medicare Administrative Contractor (MAC), CGS Administrators, LLC is required by the Centers for Medicare & Medicaid Services (CMS) to analyze claims payment data in order to identify areas with the greatest risk of inappropriate program payment. CMS has authorized Jurisdiction 15 to conduct the Targeted Probe and Educate (TPE) review process.
  
  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. Targeted Probe and Educate Review consists of up to three rounds of review. A span of 20-40 pre or post payment claim sample will be selected for review with each round.
  
  Reviewed 9/16/2021
How and why was I selected?
- - Providers are selected based on analysis of billing data indicating aberrancies that may suggest questionable billing practices.
    
    OR
  - Provider was already on targeted review and transitioned to TPE based on error rate results.
    
    OR
  - Provider error rate results based on service specific review.
  Reviewed 9/16/2021
How many claims will be selected?
- A span of 20-40 pre or post payment claim samples will be selected for review with each round. Your notification and additional documentation request (ADR) letter or system notification will indicate if the sample is pre-payment or post-payment.
  
  Reviewed 9/16/2021
How will I know if we are selected for targeted probe and educate review?
- Providers will be notified via letter of selection for TPE. The letter will outline reason for selection, overview of TPE process, and contact information.
  
  Reviewed 9/16/2021
How long does each round last?
- - The length of the round is dependent upon the provider's response to the ADR. Providers who do not respond to ADR requests will be contacted. Non-responses to ADRs will count as an error when calculating the error rate. Subsequent Rounds will begin 45-56 days after education is completed.
    Example:
    
    Round 1 Educational Call completed on 11/1/2017
    Round 2 TPE will begin as early as 12/16/2017
  - Upon completion of each round of review, providers will be offered an individualized educational session. During this education session, an educator will walk through each claim found to be in error, as well as answer any questions regarding the policy or the TPE process. CGS offers webinars, which are web-based presentations using internet technology, and traditional teleconferences. We can offer other methods of direct communication if these methods are not convenient.
  Reviewed 9/16/2021
What information do I need to submit with the additional documentation request (ADR)?
- An ADR letter or system notification will be sent on claims selected for review. This letter/notification 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.
  
  Reviewed 9/16/2021
How will I be notified of my results?
- Upon completion of the probe review sample, a letter will be mailed with the results of all claims reviewed. Providers can also access the payment system or myCGS, the CGS web portal for information regarding the payment or denial of the claim.
  
  Reviewed 9/16/2021
When will I receive my results?
- Medical Review will 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. CGS has 30 days from the date the documentation is received to review the documentation, and make a payment determination.
  
  Reviewed 9/16/2021
What happens after each round of review?
- The TPE review process typically includes up to three rounds of review with education. If there are continued high error rates after three rounds, CGS will refer the provider to CMS for additional action, which may include additional rounds of TPE review, 100% prepay review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Discontinuation of review may occur if appropriate improvement, or an error rate below the target threshold is achieved during the review process.
  
  Reviewed 9/16/2021

How can I request education?

Part A	J15APROBEANDEDUCATION@cgsadmin.com
Part B:	J15BPROBEANDEDUCATION@cgsadmin.com
HHH:	J15HHPROBEANDEDUCATION@cgsadmin.com

Reviewed

9/16/2021

What if I have questions while under review?

Part A	J15APROBEANDEDUCATION@cgsadmin.com
Part B:	J15BPROBEANDEDUCATION@cgsadmin.com
HHH:	J15HHPROBEANDEDUCATION@cgsadmin.com