Medical Review Frequently Asked Questions (FAQs)

Q1. How do I know what the signature requirements are for medical documentation?
A1. For a note to be valid, it must be authenticated by the author. The signature shall be handwritten or an electronical signature and must be legible. More information can be found at the following link: https://med.noridianmedicare.com/web/jeb/cert-reviews/signature-requirements

Q2. Are Targeted Probe and Educate (TPE) reviews being suspended with the COVID-19 pandemic?
A2. CMS has instructed Medicare Administrative Contractors to suspend pre-payment medical reviews during the emergency period due to the COVID-19 pandemic. Because this is an unprecedented and fluctuating situation, please watch for updates on the CMS and Noridian websites. For more information on the suspension of TPE reviews please see the COVID-19 FAQ.

Q3. Is acupuncture a covered service for a Medicare beneficiary?
A3. Acupuncture is only covered for the diagnosis of chronic low back pain (cLBP) for services performed on or after January 21, 2020. No more than 20 acupuncture treatments may be administered annually, treatment must be discontinued if the beneficiary is not improving or regressing, and treatment must be furnished by a physician. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs), and auxiliary personnel may also furnish acupuncture if they meet all applicable state requirements and have a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM) and a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. Please refer to National Coverage Determination (NCD) 30.3.3 for all of the coverage requirements.

Q4.  What happens if I fail one of the Targeted Probe and Educate (TPE) rounds?
A4.  You will be provided with the opportunity to have an educational E-visit regarding the review findings and then there will be a subsequent round of claim review. If all three rounds of the review are failed, you will be referred to CMS for further determination. More information on the TPE process can be found at:  https://med.noridianmedicare.com/web/jeb/cert-reviews/targeted-probe-educate

Q5. I am having a Targeted Probe and Educate (TPE) review.  My claims are getting denied because no documentation was received by Noridian. I did not get the Additional Documentation Request (ADR) letters requesting any documentation. How can I prevent these denials from happening?
A5. Your contact information must be current with Provider Enrollment at Noridian. This can be checked by calling Noridian at 855-609-9960. The pay to address is the address to which the ADR letters are mailed to. If you are not physically at that address, make sure that someone checks the mail for the ADR letters and have them notify you of any correspondence from Noridian. Per Internet-Only Manual (IOM) Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3, the documentation needs to be received by Noridian within 45 days as on day 46 it will deny out for no documentation. Noridian may refer providers/suppliers to Recovery Auditor contractor or ZPIC/UPIC if they do not respond to ADR requests and submit the requested documentation to Noridian.

 

Last Updated Fri, 19 Jun 2020 13:30:49 +0000