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CGS Administrators, LLC

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Targeted Probe and Educate (TPE) Review Program

Beginning July 3, 2017, CGS Jurisdiction C DME MAC will begin the TPE review program. The goal of TPE is to improve the claims payment error rate and reduce the volume of appeals through claim review and education.

TPE Process

TPE will include up to three rounds of supplier-specific prepayment probe reviews followed by education to improve identified errors. If a high error rate persists following the maximum rounds of review and education, CGS will refer the supplier to CMS for possible further action.  In addition, discontinuation of TPE may occur at the conclusion of any round if sufficient improvement is achieved through claim review.

How are the TPE suppliers chosen?

CGS will utilize existing data analysis processes to determine the item(s) and suppliers to review through TPE. Reference: CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.2External PDF

What can Jurisdiction C suppliers expect?

What if Error Rate Does Not Indicate Improvement?

If selected for review, suppliers are not excluded from other Medical Review activities, such as, automated reviews, other review programs, prior authorization, etc. as directed by CMS or other contractor reviews. Additionally, CGS will continue to work with other CMS contractors and collaborate with referrals back and forth to the UPIC for concerns related to potential fraud/abuse and Recovery Auditor (RA) for collaboration of vulnerability and to ensure there is no duplication of reviews.

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