Friday, April 30, 2004

Dealing with a probe review
With Peggy Walker

Q. What is a probe review?

A. A probe (prepay) review is when a specific HCPCS code or group of codes is going to be stopped and looked at by the Medical Review team before it pays.

What happens than?

The claim is “developed” which means a letter is sent to the provider requesting specific information. Of course, the letter would be specific to the item being reviewed but usually includes:

- A copy of the order for the item.

- A delivery slip for the item.

- Manufacturers information on the item.

- And a copy of the physician’s progress notes relating to the item.

You will have 30 days to respond to this development letter before your claim denies. Respond with what they ask for and nothing more or less.

When you recieve the letter:

- Respond within the time limit requested.

- Do not ignore any type of development letter regardless of the minimal amount involved or where it comes from.

- Make sure your staff understands what to do.

If you find out a code is on prepay, you do not have to submit hard copy. Continue to bill electronic, but make sure all information that will be requested is in your files.

When you receive the development letter respond immediately, the quicker you respond the quicker you get paid.

To prepare for a probe review:

- Make sure you have correct dispensing orders and detailed written, delivery tickets, orders. CMNs should be the same as they were keyed.

- Determine that the patient was actually “seen” by a physician..

- Check delivery tickets and make sure they are being done correctly.

Peggy Walker, RN is Billing & Reimbursement Advisor for U.S. Rehab: 800-642-6065