CHA News Article

Noridian to Conduct Targeted Probe and Educate Pilot Review Process

In a recent bulletin, the Centers for Medicare & Medicaid Services (CMS) announced it has authorized Noridian, California’s Medicare administrative contractor, to conduct the targeted probe and educate (TPE) pilot review process required for providers targeted by medical review. The TPE process includes three rounds of a prepayment probe review with provider education. If high denials continue after the first three rounds, Noridian will refer the provider and results to CMS. CMS will determine additional action, which may include extrapolation, referral to the zone program integrity contractor (ZPIC) or referral to recovery audit contractor.

If selected for this review, providers would not be excluded from other medical review activities, such as automated reviews, comparative billing reports, mandated demand bill reviews, other pilot review strategies as directed by CMS or other contractor reviews. Additionally, Noridian will continue to work with other CMS contractors and collaborate with referrals to quality integrity organizations for concern of quality care, ZPIC for concerns related to potential fraud/abuse, and recovery audit contractors for collaboration of vulnerability and to ensure no duplication of reviews.