Medical Review Frequently Asked Questions (FAQs)

Q1. Why is a provider chosen for a Targeted Probe and Educate (TPE) review? Is it due to the number of Medicare patients seen or the Comparative Billing Report?
A1. The TPE is not a question of the type of care being provided to patients. It is instead a documentation/billing compliance review. Noridian is obligated as the Medicare Administrative Contractor (MAC) for your jurisdiction to ensure that regulations are being followed with services provided to Medicare beneficiaries to protect the Medicare trust fund. Any claims we have selected for review that are meeting the requirements for payment that are medically necessary will be released for payment. Any provider that bills Medicare does have a possibility of being placed on a review. Providers are not selected due to a CBR (Comparative Billing Report) statistics. They are chosen based on billing analysis throughout the JF Jurisdiction. Noridian case managers are here to assist providers with the process. We are here to make sure the documentation is meeting the code requirements. View the TPE webpage for details.  

Q2. My provider is on a TPE review. How many Additional Documentation Request (ADR) letters will be sent?
A2. TPE cases average 40 claims per review but due to the complexities of the system, audits occasionally max out below the 40-claim goal. Once a provider receives a Findings Letter, he/she will not be sent another one for that case number. If a provider is moving on to a subsequent round, he/she will resume receiving ADR letters after the date the next round starts. That date can be found in the closing paragraph of the findings letter. Email the case manager questions about the ADR letters received.

Q3. I am on a TPE review for physical therapy claims. I have received denials related to the certifications. What is wrong with my claims?
A3. Individual claim questions should be directed to your case manager. Most denials related to certifications are related to gaps in the coverage of time between certifications. Example: Signed Certification 1/1-2/25. Re-certification created and signed by physician on 3/18. Any services between 2/26 and 3/17 would not be covered by a certification and would be denied.

Q4. Why are my claims getting denied for "no documentation submitted" and what can I do to keep it from happening in the future?
A4. The CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section states: "When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46." Make certain that your mailing address is current with Provider Enrollment and that your office staff knows to be watching for the ADR letters.


Last Updated Sep 25, 2019