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Targeted Probe and Educate Strategy and the NGS Medical Review Process
October 25, 2017As directed by CMS, effective 10/1/2017, NGS Medical Review will transition all lines of business to a Targeted Probe and Educate (TPE) strategy. The purpose of this transition is to reduce costs related to improper payments and appeals, therefore reducing provider burden. In order to avoid claim processing delays it is important that providers respond to ADR in a complete and timely manner. The MAC will make and document review determinations within 30 calendar days of receiving the provider’s requested documentation. On rare occasions, MR may conduct post payment claim reviews. In the post payment probe process, a sample of paid claims is selected and MR requests records from the provider in a letter that summarizes the probe process and includes a list of specific claims for which the provider must copy and submit medical records to support the service. Providers must submit medical records as directed by the MR notice letter within 45 days of the record request. In certain circumstances, an extension may be granted on this timeframe, through contact with the reviewer who initiated the request.