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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

  1. 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.
    Please see the Medical Review Activity Log for a list of review topics.
  2. 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
  3. 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.
  4. 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.
  5. 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
  6. 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.
    Please email questions or education requests to: J15AMReducation@cgsadmin.com.
  7. 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

Updated: 04.30.2026

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