What states does Novitas Solutions cover as a Medicare Administrative Contractor?

Novitas Solutions, Inc. administers two Medicare Administrative Contractor jurisdictions. Jurisdiction H covers Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas. Jurisdiction L covers Delaware, the District of Columbia, Maryland, New Jersey, Pennsylvania, and specific Northern Virginia counties and cities. Novitas does not process Medicare Part A or Part B claims in Florida, Puerto Rico, or the U.S. Virgin Islands; those claims go to a different Medicare Administrative Contractor, First Coast Service Options.

What happens after three rounds of Targeted Probe and Educate?

A provider does not get a fourth Targeted Probe and Educate round. If an error rate has not improved after three rounds of 20 to 40 claims each, the Medicare Administrative Contractor refers the matter to CMS. CMS can then order 100 percent prepayment review, extrapolate the sample findings across the full claims universe, or refer the provider to a Recovery Audit Contractor. Each of those outcomes carries materially higher exposure than the original probe.

How does a provider appeal a Novitas audit finding?

A provider has 120 days from receipt of the determination to file a redetermination request, the first level of the Medicare appeals process, with Novitas as the Medicare Administrative Contractor that issued the decision. The request must be in writing, using form CMS-20027 or an equivalent written statement, and Novitas generally issues its decision within 60 days of receipt. Missing the deadline forecloses this level of appeal.

Novitas Solutions Medicare Audits: TPE, Prepayment Review and Appeals

Novitas Solutions, Inc. is the Medicare Administrative Contractor for two federal jurisdictions spanning eleven states, the District of Columbia, and part of Northern Virginia. A provider billing Medicare Part A or Part B in Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, Delaware, Maryland, New Jersey, or Pennsylvania answers to Novitas when a claim is flagged for review. A Targeted Probe and Educate (TPE) notice, a prepayment hold, or an additional documentation request (ADR) from Novitas is the opening move in a federal claims review process that can end in extrapolation, 100 percent prepayment review, or referral to a Recovery Audit Contractor.

Novitas Solutions' Medicare Jurisdictions

The Centers for Medicare & Medicaid Services (CMS) assigns Medicare Part A and Part B claims processing to a Medicare Administrative Contractor in each jurisdiction. Novitas Solutions, Inc. holds two of these contracts. Jurisdiction H covers Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas. Jurisdiction L covers Delaware, the District of Columbia, Maryland, New Jersey, and Pennsylvania, plus Part B claims only from Arlington and Fairfax counties, the cities of Fairfax and Falls Church, and the city of Alexandria in Virginia. CMS confirmed Novitas as the Jurisdiction H contractor in June 2026 and has held Jurisdiction L since 2012, with the contract most recently re-awarded in 2021. Novitas does not process Medicare claims in Florida, Puerto Rico, or the U.S. Virgin Islands; a different Medicare Administrative Contractor, First Coast Service Options, holds that jurisdiction.

How Novitas Selects Claims for Review

Novitas conducts medical review through prepayment review, postpayment review, and Targeted Probe and Educate. Under TPE, Novitas reviews 20 to 40 claims and the supporting medical records for a single service, diagnosis, or billing pattern, selected through the contractor's own data analysis. A provider in a TPE round gets at least 45 days to make changes before the next round of claims is reviewed. If the error rate has not improved after three TPE rounds, Novitas refers the matter to CMS, which can order 100 percent prepayment review, extrapolation across the full claims universe, or referral to a Recovery Audit Contractor (RAC). A companion article, Failing Round Three of TPE: What Happens Next, covers that escalation path in more detail.

Responding to a Novitas Documentation Request

A Novitas ADR gives the provider 45 calendar days from the date of the letter to submit the requested records, under 42 C.F.R. § 405.903. Missing that deadline results in the claim being decided on the record as it stands, which generally means denial. Novitas accepts the requested documentation through its online provider portal, Novitasphere, or by mail or fax to the address printed on the ADR letter itself. A contractor may accept documentation received after the 45-day window only for good cause, such as a natural disaster or another extenuating circumstance recognized under the governing regulation.

A provider who fails three rounds of Targeted Probe and Educate does not get a fourth. The next step is a referral to CMS, and the options from there include full prepayment review and extrapolation across the entire claims sample.

Appealing a Novitas Audit Finding

A provider who disagrees with a Novitas claim determination has 120 days from receipt of that determination to file a redetermination request, the first level of the Medicare appeals process. The request goes to Novitas, the Medicare Administrative Contractor that issued the determination, using the Medicare Redetermination Request form (CMS-20027) or a written statement containing the elements the form requires. Novitas generally issues its redetermination decision within 60 days of receipt. A separate and earlier filing, the rebuttal statement, can be made before recoupment begins; a companion article, Filing a Medicare Rebuttal Statement Before Recoupment Begins, covers that narrower window.

Why early legal counsel is critical. It is critical that providers in Novitas's jurisdictions promptly retain experienced healthcare defense counsel upon receiving a TPE notice, an ADR, or any other Novitas audit communication. Early legal intervention can protect the provider's rights, help prepare a complete and accurate response to the contractor's request, preserve relevant defenses, and allow counsel to communicate with Novitas on the provider's behalf. Delaying legal representation can significantly affect the outcome of a matter and expose the provider to unnecessary risk, including escalation to 100 percent prepayment review or a Recovery Audit Contractor referral.

How Health Law Alliance can help. Health Law Alliance represents providers and suppliers nationwide in Medicare Administrative Contractor audits, including matters before Novitas Solutions in both of its Medicare jurisdictions. 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 Novitas TPE notice, prepayment hold, or ADR, schedule a free consultation with our Medicare audit defense attorneys to review the notice and the response timeline before you reply.