The latest on CMS Pre-Claim Review Demonstration for Home Health

 In Home Health, Regulatory

Home health pre-claim*updated March 31, 2017

What you need to know about the demonstration

If you’ve been following Pre-Claim Review for home health, you know that while five states were slated to launch the demonstration, as of this writing (March 1st, 2017), only one state is active NOW PAUSED under this demonstration: Illinois. Florida is delayed, but on the schedule for April 1, 2017. Now delayed again as of March 31, 2017. However, lawmakers are currently urging the administration to delay again. Below is a current status update of the five Pre-Claim Review states:

  • Illinois – August 1, 2016 (now paused)
  • Florida – October 1, 2016 – now April 1, 2017 (with active lobbying to delay further) delayed with minimum 30-day notice to re-enact
  • Texas – December 1, 2016 – Delayed with minimum 30-day notice to re-enact
  • Michigan – January 1, 2017 – Delayed with minimum 30-day notice to re-enact
  • Massachusetts – January 1, 2017 – Delayed with minimum 30-day notice to re-enact

What You Need to Know

  1. Home health providers are required to obtain a pre-claim review for home health episode services prior to submission of a final claim.
  2. The episode is to be “affirmed” prior to submission. The MAC has 10 days to review and determine whether a claim is affirmed.
  3. Affirmed episodes will be issued a Unique Tracking Number (UTN) that must be included when submitting the final claim.
  4. CMS states that the pre-claim review demonstration does not require new documentation requirements. Instead, the same documentation is required, just earlier in the process.
  5. LUPA episodes do not require pre-claim documentation.
  6. Technically, pre-claim review is optional, but claims submitted without a pre-claim review decision will be paid with a 25% reduction of the full amount.

Steps to Prepare for Pre-Claim Review

  • Stay up on the news, especially if you’re in one of the Pre-Claim Review states. If you’re not, it would be wise to follow along to see how the demonstration is playing-out for other providers.
  • Take a closer look at the process providers are undergoing. If you’d like to see what intermediaries are requiring agencies to submit, take a look at the Palmetto Submittal Request.
  • Make sure your processes are streamlined. Processes that will need to be scrutinized at your agency include:
    • Intake and referral management
    • 485 and physician orders tracking
    • Face to face encounters
  • Designate who might be in charge of submitting and managing the process. As is the case with traditional billing, the real work often begins after the claim is submitted.
  • You can find more information from your Medicare Administrative Contractor (MAC): Palmetto, NGS, or CGS
Home Health Pre-Claim Review

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