Palmetto GBA administers Medicare Part A and Part B claims in North Carolina, South Carolina, Virginia, and West Virginia as Jurisdiction M, and in Alabama, Georgia, and Tennessee as Jurisdiction J. It also runs the Jurisdiction M Home Health and Hospice Medicare Administrative Contractor across a wider footprint that reaches into Florida, Texas, and several other states. A physician practice or home health agency inside any of those jurisdictions can be selected for Palmetto GBA's medical review program, where a Targeted Probe and Educate notice or an additional documentation request carries a real deadline and a real consequence.
Palmetto GBA's Medicare Jurisdictions and Benefit Categories
Jurisdiction M covers Part A and Part B claims under a contract Palmetto GBA has held since September 2022. Jurisdiction J covers Part A and Part B claims in Alabama, Georgia, and Tennessee, a contract the Centers for Medicare & Medicaid Services confirmed Palmetto GBA would keep administering when it reissued the award in August 2024. The Jurisdiction M Home Health and Hospice Medicare Administrative Contractor is a separate, larger footprint again, covering home health and hospice claims across states that include Arkansas, Florida, Illinois, Louisiana, and Texas in addition to its Part A and Part B territory. A physician billing Part B in Charleston and a hospice agency billing in Tampa can both be answering to Palmetto GBA, under different benefit categories and different medical review teams.
Medical Review and the Targeted Probe and Educate Process
Palmetto GBA selects providers for Targeted Probe and Educate (TPE) review using claims data: high error rates, unusual billing patterns, or services the Centers for Medicare & Medicaid Services has flagged as a financial risk to the Medicare program. A compliant provider is not selected. Each round reviews 20 to 40 claims, and a provider with denials is offered a one-on-one education session with a Palmetto GBA medical reviewer before the next round begins. CMS allows up to three TPE rounds, with at least 45 days between rounds for the provider to make changes.
A provider whose error rate does not improve after three rounds is referred to CMS for further action. That can include extrapolation of the sample error rate across the full claims universe, 100 percent prepayment review of future claims, or a referral to a Recovery Audit Contractor (RAC). Separately, CMS or a Medicare contractor can impose a payment suspension under 42 C.F.R. § 405.371 on reliable information of an overpayment or a credible allegation of fraud, independent of the TPE referral.
Responding to a Palmetto GBA Additional Documentation Request
A Palmetto GBA additional documentation request (ADR) is the mechanism behind most postpayment medical review, including the claims pulled for TPE. Under 42 C.F.R. § 405.929(b)(1), a provider has 45 calendar days from the date of the ADR to submit the requested medical records. A claim with no response on file denies automatically once that window closes, and the result becomes a recoupment demand rather than an open documentation question. Palmetto GBA's medical reviewers check the submitted records against the local coverage determination for the benefit category and jurisdiction where the claim was billed, which is why a modifier 25 audit is worked differently from a home health or hospice ADR.
A Palmetto GBA additional documentation request carries a 45-day federal deadline, and a claim with no response on file denies automatically once that window closes.
Finding Palmetto GBA's Coverage Policies and Review Guidance
Palmetto GBA's local coverage determinations, proposed LCDs, and coverage articles are indexed by contractor and by state in the Medicare Coverage Database that the Centers for Medicare & Medicaid Services maintains. A provider preparing a TPE response or an ADR submission should pull the LCD that covered the billed service as of the date of service, since Palmetto GBA periodically revises its coverage criteria.
Why Early Legal Counsel Is Critical
It is critical that a provider in a Palmetto GBA jurisdiction promptly retain experienced healthcare defense counsel upon receiving a Targeted Probe and Educate notification, an additional documentation request, or notice of a referral for further review. Early legal intervention can protect the provider's rights, help make sure the response addresses the specific local coverage determination and benefit-category rule at issue, avoid inadvertent admissions, and allow counsel to communicate with Palmetto GBA's medical review department on the provider's behalf. Delaying legal representation can affect a matter's outcome and increase exposure to a referral for further action.
How Health Law Alliance Can Help
Health Law Alliance represents physicians, home health agencies, and other providers in Medicare audit defense across every MAC jurisdiction, including the Targeted Probe and Educate reviews and additional documentation requests that Palmetto GBA administers in Jurisdiction M and Jurisdiction J.
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.
If your practice or agency has received a Palmetto GBA Targeted Probe and Educate notice or an additional documentation request, contact Health Law Alliance's Medicare audit defense team for a free, confidential consultation.
