Targeted Probe and Educate

Published 08/28/2024

The Centers for Medicare & Medicaid Services (CMS) Targeted probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals by identifying provider errors, helping correct them, and prevent future errors. Medicare Administrative Contractors (MACs) have been tasked by CMS to identify high denial rates or unusual billing practices and work one-on-one with those providers to reduce claim errors and payment denials; MACs are also expected to review items and services that have high national error rates and are at a financial risk to the Medicare program.

MACs are assigned by CMS to review provider, service, and beneficiary specific data, as well as national, regional, and state historical claims data. The MACs are also supplied with reports from CMS and other government agencies and contractors such as the Office of the Inspector General (OIG), the Government Accountability Office (GAO), Comprehensive Error Rate Testing (CERT), and the Recovery Auditor (RA). Internal and external data reports identify utilization and trending patterns specific to high volume, high cost, and/or a change in frequency. Providers whose claims are compliant with Medicare policies will not be selected for TPE edits.

The TPE Process

Graphic of the TPE process: Selection, Notification, ADR, Cycle

TPE Error Rate

TPE error rates are identified by a Charge Denial Rate (CDR) and Claim Line Denial Rate (CLDR). An error rate of greater than 20 percent may result in subsequent TPE cycles. Error rates are calculated as follows:

CDR: Charges Denied/Charges
Example: $500/$1,000 = 50% CDR
CLDR: # of Denied Claims/Total Claims
Example: 20 Denied Claims/40 Total Claims = 50% CLDR

The TPE Cycle

The TPE Cycle

Results Letter

A detailed results letter will be sent to the provider at the conclusion of each round. The results letter will outline the TPE process, payment and claims error rates, release, or retention from medical review and subsequent TPE rounds, as well as provide reasons for claims/payment denials specific to Medicare regulations. Please review the results letter in its entirety for important information regarding the education process, additional rounds of review, and the process for appeals.

Point of Contact

All providers are responsible for maintenance of appropriate contact information in the Medicare system; this will ensure that any and all Medicare correspondence (including: additional documentation requests, notification, and results letters) reach the provider in a timely manner. When a provider receives a request additional documentation request (ADR), a point of contact form should also be completed and included with all medical record documentation.

ADR and TPE Resources


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