Targeted Probe and Educate (TPE) Ask-the-Contractor Teleconference (ACT) – December 15, 2021
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- How can you tell if a denial is related to a TPE?
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The ADR letter indicates the type of review, for TPE review, the ADR letter says "the review is based on Targeted Probe and Educate, TPE."
Published: 01.11.22
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- How many accounts are targeted for review? Will we be targeted on every service that we offer? How long does it take to review?
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We take into account several factors, including statistical data before we place a service under review. The services we review are posted online. Check the website for current edits.
Published: 01.11.22
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- With 2 ways of calc error rate, how do you know which is used? 20-40 files chosen – using all eligible, or are some skipped?
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At the end of the review we send to data analytics for validation of error rates. They calculate based on reviewed claims and give a claim error rate and an error rate based on $. The provider will get both error rates on the result letter Reminder: The error percentage that qualifies a provider/supplier as having a high denial rate varies, based on the service/item under review. The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. Other factors that determine the need for additional review may include but are not limited to decrease in error rate with each round, as well as participation in and improvement with education.
Published: 01.11.22
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- We received a letter a few months ago that Round 1 was completed. Will we know the results of it and what exactly was audited?
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MR has just started the TPE reviews. Providers will receive decision letters once the reviews are completed which will include the claims that were reviewed during the round.The letter a few months ago for "Round 1 completed" was for Postpayment Reviews. Quarterly Result letters were sent 12/8/21. TPE Pre and Postpayment reviews have resumed with Round 1 in progress. As each case is completed, the provider will receive a Round 1 Results letter If your review is complete you can request a follow up on your TPE review per your LOB at:
- HHH J15HHHPROBEANDEDUCATION@cgsadmin.com.
- Part A J15APROBEANDEDUCATION@cgsadmin.com
- Part B J15BPROBEANDEDUCATION@cgsadmin.com
Published: 01.11.22
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- Can all TPEs be submitted through myCGS?
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CGS encourages providers to use the myCGS portal to submit their ADR documentation.
Published: 01.11.22
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- I would like a better understanding of the SmartEdits. What can we do to bypass when a claim is denied due to the edits?
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The ACE Smart Edits were developed as a preventive measure on services that we recognize as top denials, when information is missing on the EMC, The smart edit can identify a possible denial prior to the claim being processed by returning the claim to the sender to confirm information submitted is accurate for example the units field, required documentation that may be required in the note record has been entered. Claims hitting these CGS ACE pre-adjudication Smart Edits are not forwarded to the claims adjudication system. Please review the claim and if you choose not to change the claim, then just resubmit it for processing. Current services under ACE Smart Edits:
NOTE: CGS reviews these edits frequently to see if the edit can be removed or if a new should be added based on provider Top Denied/Rejected claims.
Published: 01.11.22
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- The Department for Medicaid services in the state of KY are starting a CCBHC and requiring denials for nonbillable staff. How?
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Certain provider types and specialties are excluded from enrollment in the Medicare program (Medicare Program Integrity Manual (Pub 100-08) Chapter 10, Section 10.2.8). Therefore, they may not file claims to Medicare. Since these providers are precluded from billing Medicare, they cannot receive the traditional denial on a remittance notice.
Published: 01.11.22
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- What are helpful tips or tools for Credentialing Specialists, CMHC, and Substance Use Disorder Centers?
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The provider can also use the Provider Enrollment Interactive Help Tool. This tool will help them with the enrollment process, including which 855 forms to complete, sections required, and if any additional documents are needed. As always, Provider Enrollment Customer Service is available to answer any questions. Part A, Phone: 866.590.6703 (Option 3) Part B, Phone: 866.276.9558 (Option 3) Here is a link that you may find helpful.
Published: 01.11.22
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