The following are the most frequently asked questions about TriCenturion and the Medical Review process
Q: What is a Full PSC and what is it purpose?
A: TriCenturion performs all Medicare Program Integrity functions for DME Jurisdiction A/B. These functions include medical policy development, fraud investigations, pre-pay and post-pay medical review of claims, and data analysis. TriCenturion works closely with the Medicare Administrative Contractors (MAC) National Heritage Insurance Company (HNIC) for Jurisdiction A and AdminaStar Federal for Jurisdiction B. The MACs continue to perform program management functions for their respective region.
Q: Where does TriCenturion get its authority?
A: The statutory authority for all Program Safeguard Contractors is in §1893 of the Social Security Act (42 U.S.C. §1395ddd). It states, in pertinent part, that "[t]here is hereby established the Medicare Integrity Program (in this section referred to as the 'Program') under which the Secretary shall promote the integrity of the medicare program by entering into contracts ... with eligible entities to ... [r]eview ... activities of providers of services or other individuals and entities furnishing items and services for which payment may be made under this title (including skilled nursing facilities and home health agencies), including medical and utilization review and fraud review...."
Q: What is the purpose of medical review?
A: The goal of medical review is to ensure proper billing practices so that claims will be submitted and paid correctly by using the Progressive Corrective Action (PCA) process.
Q: How does TriCenturion decide what to review?
A: Data analysis is the essential “first step” in determining whether patterns of claims submission and payment indicate potential problems. If data analysis demonstrates that a potential problem exists, then a review will be initiated. The pre-pay or post-pay review may be either service specific or supplier specific
Q: What is TriCenturion’s PCA audit process?
A: Suppliers will be notified of the type of review occurring and a request for information from the medical records will be made. Specific instructions for submission of records are given in the notification letter to the supplier. Our Medical Review team will review the submitted information to determine if any problems exist. Based on the review results, we will provide education specific to the identified problems. We also calculate a Charge Denial Rate (CDR) for each supplier. We use the CDR to classify the severity of the problem minor, moderate or significant. The CDR levels are:
Minor: CDR less than or equal to 20%
Moderate: CDR greater than or equal to 21% and less than or equal to 75%
Significant: CDR greater than 75%
For moderate or significant problems, an ongoing pre-pay medical review will be initiated. Results of the review, as well as education to correct the problems identified, will be communicated to the supplier on a continual basis until the review is complete.
Q: What is a probe?
A: A probe is a random selection of claims used to evaluate whether a larger problem exists.
Q: What is a 100% pre-pay review?
A: Every claim submitted for a specific HCPCS Code will be reviewed.
Q: What is an ADR letter?
A: ADR is an acronym for Additional Documentation Request. TriCenturion creates ADR letters to request information from suppliers.
Q: The ADR letter lists examples of documentation to send. What exactly do I need to send?
A: Please submit sufficient information from the beneficiary’s medical record and your files to demonstrate the items billed are covered services, appropriately coded, and meet the relevant reasonable and necessary criteria for the identified items provided to the beneficiary. Please refer to the Supplier Manual: Region A, Chapter 9, page 12, or Region B, Chapter 15, page 9 for information on documentation. Sources for this information may include the following (not all-inclusive).
• Physician progress notes
• Non-physician clinician progress notes (if applicable)
• In-person evaluations (if applicable)
• Certificates of medical necessity
• Physician’s written orders
• Delivery ticket with name, address and signature of beneficiary, and equipment provided
• Physical/occupational therapy notes (if applicable)
• Invoice including manufacturer name and model number
• Any other pertinent documentation, which would support the medical necessity of the item billed
Q: What is considered medical documentation?
A: Medical information showing that the relevant policy criteria are met comes from the beneficiary’s medical record. The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home or home health agency records, and records from other professionals including, but not limited to, nurses, physical or occupational therapists, prosthetists and orthotists.
Q: The Local Coverage Determinations (LCDs) do not say I need to keep documentation in reference to reasonable and necessary criteria. How can TriCenturion expect me to get it months after I supply the DME?
A: The Documentation Requirement section of both the LCDs and the Supplier Manuals, read that the documentation must be made available to the DMERC upon request. It is the decision and responsibility of suppliers to determine their own process for ensuring the documentation is available if requested. For example, many suppliers report that when they receive the order for DME they request the medical documentation at that time and do not supply the DME until they have the documentation.
Q: How can I get up to date information about what is pertinent to me as a supplier?
A: Please sign up for the TriCenturion listserv found on the home page of our Web site at www.tricenturion.com. This listserv will alert you to LCD revisions and publications to our Web site. You can also visit www.medicarenhic.com (Jurisdiction A) or www.adminastar.com (Jurisdiction B) for additional information related to durable medical equipment billing.
Q: If I have a question, whom do I contact?
A: Please call the appropriate Medicare Administrative Contractor (MAC) customer service number: Jurisdiction A-National Heritage Insurance Company at 1- (866)-419-9458 or Jurisdiction B AdminaStar Federal at 1-877-299-7900. However, if you are involved in a medical review audit with TriCenturion, you may call us directly at the contact number provided in your audit letter.
Medical Review