CMS Resumes Targeted Probe and Educate

As reported previously, CMS has announced the resumption of Targeted Probe and Education (TPE) reviews. Although there is not yet much additional information available, we understand that there may be more detail coming from the MACs in the near future.

Until then, checking claim status codes may help providers identify any claims that might be part of TPE reviews. The following reminder is provided by Palmetto but applies to all MACs including CGS:

• When a claim is selected for possible Targeted Probe and Educate (TPE) review, it will go into an S B6000 location in Direct Data Entry (DDE). When the claim goes to this location there will be narrative that indicates the claim was selected and documentation is requested. However, you should not respond with medical documentation unless the claim moves to S B6001 location. When a claim goes into S B6001 location, it generates an Additional Document Request (ADR) and it will hold in that location until the records are received.

• Claims initially suspended into location S B6000 may not advance to S B6001 for review and could be released for processing without review. Only claims that are selected for review will move from S B6000 to S B6001. Do not send in medical documentation unless the claim suspends to location S B6001, when the ADR will be generated.

• However, when and if the claim moves to SB6001 and you need to send in documentation, please refer to your ADR letter to ensure you provide the MAC with the documents needed to process your claim.