Noridian Healthcare Solutions administers Medicare Part A and Part B claims for two separate contractor jurisdictions and durable medical equipment (DME) claims for two more, so the same practice can face different Noridian review rules depending on the claim type and the state. A physician or supplier who just received a Targeted Probe and Educate notice or an additional documentation request from Noridian needs to know which jurisdiction governs the claim, and how Noridian's medical review and appeals process actually works, before responding.
Noridian's Medicare Jurisdictions
Noridian holds four separate Medicare Administrative Contractor (MAC) contracts. As the Part A/B MAC for Jurisdiction E, it processes Part A and Part B fee-for-service claims for California, Nevada, Hawaii and three Pacific territories. As the Part A/B MAC for Jurisdiction F, it processes Part A and Part B claims across ten states stretching from Alaska and Washington to Arizona and Wyoming. Noridian is separately the DME MAC for Jurisdiction A, covering eleven Northeast and Mid-Atlantic states plus the District of Columbia, and for Jurisdiction D, covering much of the West and parts of the Midwest. A DME supplier and a physician practice in the same state can answer to two different Noridian jurisdictions, reviewed by two different teams.
The same contractor-specific split shows up elsewhere; Novitas Solutions operates its own two-jurisdiction Medicare contract covering a separate set of states, under the same jurisdiction structure CMS uses nationwide.
Medical Review and the Targeted Probe and Educate Process
When Noridian's data analysis flags a billing pattern, often tied to a local coverage determination or a national error-prone service, it sends an additional documentation request. Under 42 C.F.R. 405.929, a provider has 45 calendar days from the date on the ADR letter to submit the supporting records; claims without a response by day 46 are denied. Providers selected into Noridian's Targeted Probe and Educate review face up to three rounds of 20 to 40 claims each, with individualized education after every round on the specific errors found, sometimes a documentation gap, sometimes a coding pattern such as unsupported modifier 59 billing.
A provider who reaches an acceptable error rate after any round will not be reviewed again on that topic for at least a year. A provider who still shows a high error rate after three rounds is referred to CMS for next steps, which can include 100 percent prepayment review, extrapolation of the sample error rate, or referral to a Recovery Auditor (RAC).
How Noridian's Redetermination Unit Handles Appeals
A provider who disagrees with a Noridian determination can request a redetermination, the first of five Medicare appeal levels. A redetermination is reviewed by Medicare Administrative Contractor personnel who were not involved in the initial determination. The deadline to file is 120 days from receipt of the initial determination, there is no minimum dollar amount required to appeal, and Noridian generally must issue its decision within 60 days of receiving the request. Evidence not submitted by the time the QIC issues its reconsideration decision must come with a statement explaining why, or it will not be considered at the hearing level that follows, which is why building the record early deserves the same attention as the recoupment demand itself. We cover the record-building tactics for that stage in Medicare Redetermination: Winning at Level One.
A Noridian Targeted Probe and Educate notice is a data-driven test of one billing pattern, round by round, with a referral to CMS waiting at the end of it.
Why Early Legal Counsel Is Critical
It is critical that physicians and suppliers promptly retain experienced healthcare defense counsel upon receiving a Targeted Probe and Educate notice, an additional documentation request, or a Noridian redetermination denial. Early legal intervention can protect the provider's rights, help ensure accurate and complete responses to Noridian's requests, avoid inadvertent admissions, preserve the evidentiary record for every appeal level, and allow counsel to communicate with Noridian on the provider's behalf. Delaying representation can affect the outcome of the review and expose the provider to recoupment and extrapolation risk that a timely response could have avoided.
How Health Law Alliance Can Help
Health Law Alliance represents physicians, physician practices, and durable medical equipment suppliers in Noridian medical review, Targeted Probe and Educate audits, and Medicare audit defense from the first additional documentation request through redetermination and beyond.
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.
If your practice has received a Noridian Targeted Probe and Educate notice or an additional documentation request, contact Health Law Alliance's Medicare audit defense team for a free, confidential consultation.
