Glossary / TPE
TPE Targeted Probe and EducateTPE (Targeted Probe and Educate)
A MAC medical review program: up to three rounds of 20 to 40 claims each, with one-on-one education between rounds, for suppliers with high error rates.
Targeted Probe and Educate (TPE) is the medical review program the MACs use for providers and suppliers whose billing data shows high claim error rates or unusual patterns, or who bill items with high national error rates. Instead of a one-time audit, the MAC pulls a probe sample of 20 to 40 claims, requests records through ADRs, reviews them, and then offers one-on-one education on the errors it found.
A supplier that does not show enough improvement moves to a second and, if needed, a third round, with at least 45 days after each education session before new claims are selected. Suppliers still failing after three rounds are referred to CMS, which can impose 100 percent prepayment review, extrapolation of the error rate, referral to a Recovery Audit Contractor, or other action. A supplier that passes is not reviewed on that topic for at least a year.
TPE ADRs follow the usual response rules: the DME MACs give 45 days to send the records, and a non-response counts against you. Because a round is only a few dozen claims, one or two missing proof-of-delivery slips or unsigned orders can be the difference between passing and a second round.
Common questions
How do I know I am in TPE?
The MAC sends a notification letter before the first probe. ADRs then arrive for the sampled claims.
What happens after three failed rounds?
Referral to CMS. The options CMS lists include 100 percent prepayment review, extrapolation, and referral to a Recovery Auditor.
How is TPE different from an ordinary ADR?
The mechanics are the same, but TPE is a program with rounds, education, and escalation. An individual ADR is one claim; a TPE round is a sample judged as a set.
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Sources: CMS: Targeted Probe and Educate (TPE) · CGS DME MAC Jurisdiction C: Targeted Probe and Educate · CMS Program Integrity Manual, Chapter 3 (TPE post-probe activity) . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Prior authorization
- Affirmation and non-affirmation
- UTN — Unique Tracking Number
- SWO — Standard Written Order
- Face-to-face encounter
- DME MAC — Durable Medical Equipment Medicare Administrative Contractor
- Jurisdiction
- PTAN — Provider Transaction Access Number
- NPI — National Provider Identifier
- MBI — Medicare Beneficiary Identifier
- LCD — Local Coverage Determination
- NCD — National Coverage Determination
- Policy article
- HCPCS — Healthcare Common Procedure Coding System
- Length of need
- Prior authorization exemption
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- Prepayment review