Targeted Probe and Educate

Targeted Probe and Educate
Key Elements of TPE
Provider Tips
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National Government Services restarted targeted probe and educate reviews on 9/1/2021.

Targeted Probe and Educate

CMS’ TPE program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. CMS expanded the TPE pilot program on 10/1/2017 to include all MACs. TPE has targeted medical review and education and an option for potential elevated action, up to and including referral to other Medicare contractors including the UPIC, RAC, etc.

Please note: Some TPE reviews involve claims that have already been processed (postpayment). TPE reviews that are being done for new claim submissions (prepayment) will include a notification letter followed by separate ADRs for each claim involved. The notification letter for postpayment TPE reviews will list all the claims being selected for review for the round.

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Key Elements of TPE

MAC medical record reviews include up to three rounds of TPE review. If the provider’s error rate remains high upon completion of the first round, then the provider is retained for the second and, potentially, a third round of review.
- Automated reviews and prior authorization directed by CMS are outside of the TPE strategy.
- Note that any reviews or pilots otherwise mandated by CMS are excluded from TPE.
Providers with an elevated error rate after three rounds of TPE will be referred to CMS for additional action
Your MAC will select the topics for review based upon existing data analysis procedures.
The claim sample size per provider, per topic, and a round of TPE review is limited to a minimum of 20 and a maximum of 40 claims
- Note that the sample is per provider, per topic, and per round.
The TPE process includes provider specific education that will focus on improving issues without allowing other problems to develop along with an opportunity for the provider to ask questions. Education will be offered after each round of 20 to 40 claims reviewed.
- In addition, there is an opportunity for intra-round education as well if the nurse reviewer identifies an easily curable error that can be easily corrected during the review phase.

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Provider Tips

Please review the following resources:

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Targeted Probe and Educate

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