Is this review the same as targeted probe and educate (TPE)?
No, the service-specific review is not the same as the TPE program. For additional details on TPE, please visit our TPE page.
What if I do not agree with First Coast’s determination? Does the TPE process change the current appeal process in place for Medicare providers?
What if you do not agree with First Coast's determination?
If First Coast calls for education and is unable to reach the provider, how many additional call attempts will be made?
Read about what happens when First Coast attempts to contact you.
What is an overlap?
An overlap is when an incorrect claim is processed and posted to the Common Working File (CWF) resulting in claim overlap rejection(s) of subsequent claim(s) submitted by the same or a different provider. When more than one provider is involved, the providers must work together to resolve the error. Some overlapping claim examples include:
Is there a timetable available to help determine if a claim meets the criteria as cost outlier?
Yes, the Cost Outlier timetable example is designed to assist providers in determining if a claim qualifies as cost outlier. Prior to coding an inpatient cost outlier claim, first determine the diagnosis related group (DRG) cutoff date, by using the example timetable.
Definitions
How is the error rate determined?
View this article to see how the error rate is determined.
When is it appropriate to use occurrence code 47 when submitting an inpatient cost outlier claim?
Reference the Outlier Flowchart after asking this question: Does the cost for an inpatient stay exceed the cost outlier threshold amount?