Targeted Probe and Educate

Published 04/22/2025

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

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 (POC) form should also be completed and included with all medical record documentation.

Intra-Probe Education

During the probe review, the Palmetto GBA medical reviewer may contact the designated POC for any missing information or to provide education on a specific claim or issue identified.

Easily curable calls (ECC) are made by reviewers to the provider POC to request missing documentation.  If the provider submitted a complete documentation package or there is no education requirement identified during the review, the reviewer will not contact the provider during the probe.

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.

Post-Probe Education 

After the written results letter has been issued, a reviewer or clinical educator from the Palmetto GBA Medical Review Department will contact the provider to schedule a 1:1 educational session via teleconference regarding any errors noted during the claim review. Providers do not have to complete an online educational request form for TPE education. The 1:1 TPE educational endeavor is conducted by a medical review department staff member and not by the Provider Outreach and Education staff; this is in an effort to ensure the 1:1 education is specific to the errors found during the TPE review of medical record documentation.

There are no requirements for those who should participate; anyone chosen by the organization, office, facility, to participate is welcome to join the educational session. It is recommended that providers include leadership and clinicians who document in the medical record who will benefit most from the education, as well as facilitate implementation of any necessary changes to medical record documentation and billing practices prior to subsequent rounds of TPE.

TPE Denial Rate Recalculations

A detailed results letter is sent to the provider at the conclusion of each round with their CDR and CLD denial rates. Favorable appeal results prior to the results letter issuance would be calculated in the denial rates in the letter. 

If a provider receives favorable appeal decisions after the issuance of the letter and those results bring both the CDR and CLDR below the 20 percent thresholds, the provider may request denial rate recalculations during the post-probe education session or via the Provider Contact Center. If the recalculation brings the provider below both rate thresholds, the provider may be removed from that specific TPE edit.  

Reminders:

  • A provider should not request a recalculation prior to receiving their results letter. Fully favorable appeal results will be calculated into the letter denial rates when issued.
     
  • Recalculations should only be requested if the provider’s threshold is above the 20 percent CDR and CLDR thresholds, but favorable appeal results will take them below the thresholds. 
     
  • Partial denials and down coding of services are included in the CLDR and continue to count as a claim paid in error. A claim must have no errors to not be calculated in the denial rates. 

Providers can calculate their CLDR using the Charge Denial Rate Calculator located under the Tools topic of the website.

ADR and TPE Resources


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