Review programs FAQs

Upon completion of the service-specific review, a "Post-Payment Service Specific Review Results" letter will be mailed to you detailing the outcome of the review, individual claim review determination(s) and education on the findings. The results letter will also provide contact information for the nurse who reviewed the case to assist with any additional education needs to ensure your understanding of the results, how they were determined and, if applicable, how to improve your Medicare billings.

CMS continually strives to reduce improper payment of Medicare claims per Social Security Act Sections 1833(e), 1815(a), 1862(a)(1)(A) and 1842(p)(4). As a Medicare administrative contractor (MAC), First Coast is tasked with preventing inappropriate Medicare payments. Contractors use data analysis as the foundation for detection of aberrancies or patterns of apparent inappropriate billing, which may be potential claim payment errors. Data analysis is the comparison of claim information and other related data to identify potential errors. Various sources of information and techniques are used to identify potential errors that pose the greatest financial risk to the Medicare program. When such aberrancies or inappropriate billings are identified, additional measures are taken to verify and add context to the data. One of the ways this is verified is through medical review of claims. Medical review of claims helps to ensure that Medicare pays for services that are covered, correctly billed and coded per the Medicare guidelines, and medically reasonable and necessary.  

We will notify providers who have been selected for review with an additional documentation request (ADR) or record request letter, which will include the request for records for the procedure code(s) being reviewed and the process of review. The letter will also include the nurse reviewer and/or education specialist contact information should you have additional questions.

First Coast accepts medical records via: 

• Secure Provider Online Tool (SPOT)
• By fax: Use the first page of the ADR letter as the coversheet:
  • Fax to 904-361-0318
• Electronic Submission of Medical Documentation (esMD) | CMS
• By mail: See ADR letter for mailing address and instructions
• CD/DVD

For additional information on how to send medical records, please review medical documentation

First Coast will select topics for review based on current data analysis; the most egregious providers identified during the data analysis will be selected for TPE to validate the services billed to Medicare. The procedures are outlined in CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 2.

First Coast will notify providers who have been selected for review with an initial notification letter which will include the topic being reviewed, the reasons for selection which will be supported by data analysis, and the process of review. The nurse reviewer will also call the provider to establish a contact person, introduce their self and provide initial education and information. First Coast will attempt to call one to two times for introduction.

The Initial Notification Letter includes a documentation checklist to help providers prepare documentation for submission. The documentation checklist can also be found under targeted probe and educate review topics and schedule of review.

Once an ADR is received, a provider should do the following:

• Collect all requested documentation
• Verify all documentation requested is included in your submission
• Attach the first page of the original ADR request letter as the coversheet to the records  

If you are responding to multiple MR ADR requests, clearly separate the documentation for each claim by inserting the first page for each ADR letter separately for the applicable documentation that pertains to that ADR letter/individual fax coversheet. Multiple responses sent together, but not separated, may result in the documentation being imaged as one claim or claim may be rejected completely.

One-on-one education will be provided if requested following the conclusion of the service-specific review. The results letter will include contact information for the nurse who reviewed your claims to assist with any additional education needs you may have. Our website also has additional education and resources for your reference on the service-specific topics under review.

The improper payment error rate is determined by methodology specified in the IOM, Publication 100-08 – Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, Section 3.7.1.1 – Provider Error Rate.

For post-pay probes, the improper payment calculation is as follows: the dollar amount of the services paid in error as determined by medical review is divided by the dollar amount of the services originally paid for the services under review.

For pre-pay probes, the improper payment calculation is as follows: the dollar amount of the services billed in error as determined by medical review is divided by the dollar amount of the services originally billed for the services under review.

Upon completion of the TPE review, a summary letter will be mailed to you detailing the outcome of the review as well as individual claim review determinations. The summary letter will also request that you set up a one-on-one educational call with the nurse who reviewed the case to ensure your understanding of the results, how they were determined and, if applicable, how to improve the outcome for future medical reviews.

If we are attempting to schedule education following the probe, we will make three attempts by phone before sending a letter notifying you of the attempts to contact you. 

If no response is received, or if education is declined, the next round of TPE will be initiated at least 45 days from the date of the summary letter for providers requiring additional rounds.

No, the service-specific review is not the same as the TPE program. For additional details on TPE, please visit our TPE page.

The process for appealing claim determinations remains the same. If you disagree with the determinations made by the Medical Review department, your next level of appeal is a redetermination. A redetermination is an independent re-examination of a claim. If you wish to appeal, this must be done within 120 days from the date of the demand letter. Please note that First Coast takes into consideration all appeals overturned prior to initiating a subsequent TPE round of review.

If you are unable to obtain the relevant medical record documentation for review, please contact the nurse or education specialist as outlined in your ADR/record request letter for assistance. 

A post-payment review is conducted on services / claims that have already been submitted and paid by Medicare to the provider. First Coast is required to review documentation that substantiates information reported on claims submitted for reimbursement. We do this to ensure that the Medicare program reimburses only for covered, medically necessary, items or services furnished to eligible beneficiaries by qualified providers or suppliers. The Medical Review department will be looking at services / items that are known to be frequently not billed and coded correctly per the Medicare guidelines through post-payment service specific reviews. If during the review we determine that a payment error was made, the provider will be responsible for any overpayment determined during review. 

First Coast has initiated TPE under the direction of the CMS to reduce provider burden, claim denials, and appeals through one-on-one education.

The TPE process can consist of three rounds of prepayment and/or post-payment probe reviews with one-on-one education. This will allow First Coast the opportunity to educate providers before, during and after the probe.

Providers will receive initial notification education before additional documentation requests (ADRs) are sent out to help them understand the documentation requirements for the procedure code involved with the review and how to properly submit the documentation. Education will continue throughout the review process allowing for additional documentation to be requested if resolvable errors are found while completing the review. At the end of the probe the nurse reviewer will offer an educational teleconference to provide detailed one-on-one education on errors found during the probe.

Providers with a review resulting in a zero or low error rate will not move on to the next round of TPE. Providers with a review resulting in a high error rate may move on to the next round and will receive additional education.

There is a minimum of a 45-day break between each TPE round; giving providers time to implement any changes they feel are necessary after education.

For more information, please visit the CMS TPE page of their website.

TPE review verifies that services are performed and billed appropriately based on current guidelines, including but not limited to LCDs, local coverage articles, NCDs, IOMs, and the Social Security Act (SSA).

LCDs and articles can be found by using the First Coast interactive LCD index.

In addition to using the interactive LCD index, First Coast’s LCDs and articles are available using the CMS Medicare Coverage Database. NCDs can also be found on the Medicare Coverage Database.

Additional resources can be found under targeted probe and educate review topics.

CMS requires that any Medicare service provided or ordered must be authenticated by the author -- the one who provided or ordered that service. Certain types of signatures (e.g., illegible signatures, initials) may require the addition of a “signature attestation statement” or a signature log to the documentation to ensure the signature’s authentication. If documentation submitted for medical review does not contain a signature at all, then only a signature attestation will be accepted.

CMS issued change request (CR) 6698, which clarified Medicare fee-for-service signature requirements. According to CR 6698, “In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.”

However, CMS neither requires nor instructs providers to use a specific form or format for the attestation statement.

For additional guidance, refer to the signature requirements samples on the medical documentation page of our website. 

Reference

• MLN905364 – Complying with Medicare Signature Requirements (cms.gov) 

This information is located under Policy & Review Programs, Prior Authorization, Hospital OPD Services. Review the Understanding prior authorization (PA) for certain hospital outpatient department (OPD) services for questions concerning the HOPD prior authorization process.

The ADR/development letter is mailed to a provider’s practice address on file with Medicare. 

For individual providers rendering services in large facilities such as hospitals, the ADR letter may be misdirected and/or not received in a timely manner by the appropriate department and/or individual provider.

Providers in these situations may request First Coast to mail all correspondence (including ADRs) to the “pay-to” address listed on their Provider Enrollment, Chain and Ownership (PECOS) file.

Additional information for change of address, change of information, or other enrollment information can be found here: Provider/supplier enrollment applications