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January 29, 2026

Provider Alert: Update to CGS TPE Claim Selection for SNF Providers

CGS is committed to helping providers reduce claim errors through the Targeted Probe and Educate (TPE) process. CGS is updating the sample claim collection to 20-40 claims for each round of review. For additional information, please refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, section 3.2.5External PDF.

Key Updates to TPE Review

  • Claim Sample Size: For Skilled Nursing Facility (SNF) providers currently in a TPE round who have not yet received their end-of-round results letter, CGS will collect 20-40 claims rather than the initially anticipated 20 claims.

Action Required: TPE ADR Cover Sheet

It's critical for providers to include the TPE Additional Documentation Request (ADR) Cover SheetExternal PDF with each ADR submission.

  • Designated Contacts: Identify 1-2 designated provider contacts for your facility.
  • Why it Matters: Our medical review department uses this information to reach out directly for educational opportunities or to request missing records that may prevent claim denials or changes in the Health Insurance Prospective Payment System (HIPPS) code billed.

Important Reminders

  • Prompt Return Calls: If our medical review department contacts you, please ensure a prompt return call is completed or you may miss an opportunity to prevent a claim denial.
  • Avoid Non-Response Denials: Failure to submit requested records within the required timeframe (45 calendar days) will result in a claim denial (reason code 56900).
  • Use the Checklist: Please review the PDPM ADR Checklist for resource links, tips on how to prevent common claim denials, and ADR submission tips.

Contact Information

For additional questions, please email: J15AMREDUCATION@cgsadmin.com.

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