Guides / Review types
Review types PA, ADR, prepayment and post-payment review, TPE — any equipment categoryPrior authorization vs ADR vs prepayment review vs TPE: what each means for a DME claim
Citations verified against the CMS Medicare Coverage Database · Reviewed September 2026
Medicare checks DME documentation at several points in a claim's life, and the checks have different names, different clocks, and different consequences. Prior authorization (PA) happens before delivery. An Additional Documentation Request (ADR) can arrive before payment or after it. Targeted Probe and Educate (TPE) is a multi-round program aimed at suppliers with unusual billing. They are run by the same DME MACs, and one claim can meet more than one of them.
This guide lays out each review type — who initiates it, where in the claim lifecycle it lands, how long you have to respond, and what happens if you do not.
The requirements, with citations
The elements below are drawn from the cited CMS and DME MAC sources, not from AffirmDME's rules engine.
Prior authorization: before delivery, initiated by the supplier
For items on CMS's Required Prior Authorization List, the supplier sends a request with the order and clinical records before delivering. The DME MAC issues a provisional affirmation or non-affirmation within five business days (not to exceed seven calendar days), and the affirmed claim carries a 14-byte unique tracking number (UTN). A claim for a listed item submitted without a PA decision and UTN is automatically denied.
CMS DMEPOS PA Operational Guide §5, §18.3Prepayment review and the ADR: after submission, before payment
When a MAC selects a submitted claim for medical review, it suspends the claim and sends an Additional Documentation Request asking for the records. The MAC allows 45 calendar days to respond; Noridian states that a suspended claim denies as provider liability if the ADR response is not received within that window. The ADR is not a denial, but a missed one becomes one without any review of your records.
CMS — Additional Documentation RequestPost-payment review: after payment, with recoupment on the line
MACs, the Supplemental Medical Review Contractor, and Recovery Audit Contractors can request records on paid claims, again with a 45-calendar-day response window; UPICs allow 30 days. A claim that cannot be supported becomes an overpayment to be recovered. The exemption program's annual 10-claim sample is a post-payment ADR of this kind.
CMS — Additional Documentation Request; PA Operational Guide §6.1Targeted Probe and Educate: rounds of 20–40 claims plus education
MACs select suppliers with high claim error rates or unusual billing practices, and items with high national error rates. Each round reviews 20 to 40 claims through ADRs, followed by a one-on-one education session and at least 45 days to improve before the next round. Suppliers that fail to improve after three rounds are referred to CMS for actions that can include 100 percent prepayment review, extrapolation, or referral to a Recovery Auditor; a compliant supplier is not reviewed on that topic again for at least a year.
CMS — Targeted Probe and Educate (TPE)What a provisional affirmation does and does not protect
An affirmed PA is a preliminary finding that the future claim will likely meet requirements. The claim can still deny for technical requirements that are only evaluated at claim processing, or for information that was not available at the time of the request — proof of delivery is the obvious example, since it does not exist until after the PA decision.
CMS DMEPOS PA Operational Guide §16.1What usually sinks these claims
- The ADR went to the practice address on file with Medicare rather than the branch that handled the case, and the 45 days ran out unnoticed
- A replacement or duplicate claim was submitted while the ADR was pending, which Noridian warns results in denial, rejection, or recoupment
- Proof of delivery was never collected because the PA was affirmed and the file was considered finished
- A TPE round was answered claim by claim without fixing the underlying pattern before the next 20–40 claims were pulled
One complete file answers every review
AffirmDME builds a per-item readiness checklist with citations before you submit, and when an ADR arrives it drafts the response from the documents already on the case.
See how ADR drafting worksFAQ
Which review type applies to my item?
Prior authorization applies only to items on CMS's Required Prior Authorization List. Every DMEPOS claim, listed or not, can be selected for prepayment review, post-payment review, CERT sampling, or TPE. The documentation set is the same across all of them; what changes is when it is examined.
Can I get an ADR on a claim that already had an affirmed PA?
Yes. The affirmation covers what the MAC saw at request time. Elements that only exist afterward, like proof of delivery, and technical claim requirements are still reviewable, and UPICs and the CERT contractor sample claims independently of PA status.
What is the difference between an ADR and TPE?
An ADR is the letter — the mechanism any medical reviewer uses to request records on a claim. TPE is a program: a MAC selects a supplier for up to three rounds of 20–40 claim reviews, each conducted through ADRs, with education between rounds and escalation to CMS if the error rate does not improve.
How does AffirmDME fit across these reviews?
The per-item readiness checklist and missing-document detection are meant to make the case file complete before a PA request or claim goes out, which is the same file every later review asks for. When an ADR does arrive, AffirmDME reads the letter's requests against the case documents, recommends what to enclose, and drafts the cover letter.
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This guide summarizes Medicare requirements as implemented in AffirmDME's compliance engine, with citations to the governing sources. It is not legal or billing advice; LCDs and CMS policy change — always confirm against the current policy text linked above.
Also drawn on: CMS — Medical review and education · Noridian — additional documentation requests · CGS — additional documentation requests .
More guides
- Medicare ADR Letters: how to respond without losing the claim
- Medicare DME Documentation Requirements: the checklist every claim needs
- Medicare CPAP Documentation Requirements (E0601)
- Medicare Home Oxygen Documentation Requirements (E1390)
- Medicare BiPAP / RAD Documentation Requirements (E0470)
- Medicare Hospital Bed Documentation Requirements (E0260)
- Medicare Wheelchair & Power Mobility Prior Authorization (E1161)
- Medicare Knee Orthosis Documentation Requirements (L1833, L1832)
- Medicare TLSO Documentation Requirements (L0456, L0457, L0486)
- Medicare Air-Fluidized Bed Documentation Requirements (E0194)
- Medicare Ultralightweight Manual Wheelchair Requirements (K0005)
- Medicare Upper Limb Orthosis Requirements (L3761, L3916)
- Medicare Osteogenesis Stimulator Documentation Requirements (E0747, E0748)
- The Medicare DMEPOS Required Prior Authorization List, explained (2026)
- Probationary Prior Authorization for newly enrolled DMEPOS suppliers (Oct 15, 2026)
- The DMEPOS prior authorization exemption: how it works and how to keep it
- Which DME MAC handles your claim: Jurisdictions A, B, C, and D
- Standard Written Order (SWO) requirements for Medicare DME
- Medicare DME face-to-face encounter requirements
- After a non-affirmed prior authorization: resubmit, deliver with an ABN, or wait
- Medicare DME proof of delivery requirements
- Preparing and submitting a DMEPOS prior authorization request
Unfamiliar term? The glossary defines ADR, SWO, UTN, PTAN and the rest; the PA List lookup checks any HCPCS code.