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December 18, 2015

Home Health Probe and Education and Medical Review Additional Development Requests

CGS has received instructions from the Centers for Medicare & Medicaid Services (CMS) to implement a Probe & Educate medical review strategy for home health episodes with start of care dates on or after August 1, 2015.  Five claims will be selected for each home health agency that submits claims to CGS.  As a result, a Medical Review Additional Development Request (MR ADR) will be generated with the edit 5013W.

For providers not familiar with the MR ADR process, please refer to the “Medical Review Additional Development Request (ADR) Process” at http://www.cgsmedicare.com/hhh/medreview/adr_process.html on CGS Web page for additional information.

IMPORTANT NOTE: Due to system limitations, it is likely that for some providers more than five of your claims will be selected and generate a MR ADR and will suspend in status/location S B6001 during a nightly system cycle. CGS will work to release claims in S B6001 that are in excess of the five claims.  Therefore, it is important that providers wait 24-48 hours before identifying claims that remain in status/location S B6001 before responding to MR ADRs. 

How to Identify Claims Selected for Probe and Educate
Claims selected for MR ADRs will display in status/location S B6001.  Each claim will include the reason code 39700 indicating your claim has been selected for medical review.  A secondary reason code, (probe/educate edit 5013W) will appear at the bottom of the claim screen (see below).

Screen Shot

To view the reason code narrative, press F1.  The narrative for the first reason code will display.  You will need to type the secondary reason code in the REAS CODE field in order to view that narrative.

To identify when the MR ADR was generated, access the claim page 08 (below).  The ORIG REQ DT field, located at the bottom of page 08, provides the date the ADR was generated.  If your claim includes the 5013W reason code edit, wait 24-48 hours before responding.  If the claim was in excess of the five claims, CGS will move the claim to continue processing, and the claim will no longer appear in status/location S B6001. 

Screen Shot

If the secondary reason code is a code other than the probe and education code 5013W, providers should proceed and submit the requested documentation without waiting 24-48 hours. 

MR ADR documentation may be submitted via the myCGS portal, electronic submission of medical documentation esMD, fax (1.615.664.5981) or mail.

Additional Resources

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