Targeted Probe and Educate (TPE)
The purpose of Targeted Probe and Educate (TPE) is to:
- Decrease provider burden.
- Identify and prevent improper payments.
- Reduce appeals.
- Improve the medical review and education process.
TPE Process
- Provider Selection
Based on data analysis of claims payment, CGS:- Identifies items or services with the greatest potential for improper payment.
- Initiates provider-specific prepayment or postpayment reviews.
- Provider Notification
When a provider is selected for TPE review, CGS sends a notification letter that includes:- Reason for selection
- Overview of the TPE process
- CGS contact information
- Rounds of Review
Providers selected for TPE review can expect:- Up to 3 rounds of review.
- For each round, CGS will select up to 20-40 claims (prepayment or postpayment).
- If applicable, subsequent rounds will begin 45-56 days after individual provider education is complete.
- CGS may discontinue the review if the provider demonstrates improvement and achieves an error rate below the target threshold during the review process.
- ADR Letters
For each claim selected for review:- CGS will send an Additional Documentation Request (ADR) letter.
- Submit the requested medical record documentation within 45 days.
- Upon receipt of your documentation, CGS will make a payment decision within 30 days (prepayment) or 60 days (postpayment).
- If we don’t receive a response within 45 days of the ADR letter date:
- The claim will deny (reason code 56900).
- The claim denial will count as an error when we calculate your error rate.
- Review Results Letters
At the conclusion of each round, CGS will send a review results letter that includes the number of claims:- Reviewed
- Allowed in full
- Denied in full or in part
- Provider Education
Education sessions are available via webinar, teleconference, or other methods:- CGS offers an individualized education session to providers with a moderate to high error rate. This includes the opportunity to discuss each claim found in error and address any questions or concerns.
- Any provider may also request an individual education session at any time.
- Widespread education sessions are posted on the Part A Calendar of Events.
- Review Completion
If a provider demonstrates improvement and achieves < 25% error rate during the review process, CGS may discontinue the review.
If a provider’s denial rate remains high after completing 3 rounds of review and education, CGS will refer the provider to CMS for additional action. This may include additional rounds of TPE review, 100% prepayment review, extrapolation, referral to a Recovery Auditor, or referral for revocation.
Resources
- CMS Medicare Benefit Policy Manual (Pub. 100-02)

- CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, section 3.2.5

- Navigating the Process: TPE video
- Targeted Probe and Educate | CMS

- Top Provider Questions – Targeted Probe and Educate
Updated: 04.30.2026

