CMS recently announced its implementation of the Pre-Claim Review Demonstration for Medicare certified home health agencies in select states. This is a three-year demonstration that will begin this year in Illinois, Florida, and Texas no earlier than the first day of August, October, and December respectively. The demonstration is expected to begin in Michigan and Massachusetts no earlier than January 1, 2017.
To briefly summarize the agency’s responsibility in the Pre-Claim Review (PCR) process, CMS will require home health agencies to submit a PCR request to the designated MAC or fiscal intermediary (i.e., CGS, NGS, or Palmetto GBA) prior to submitting a final claim for services provided during an episode of care under the Medicare home health benefit. The PCR request is to be reviewed within 10 business days of the initial submission to the MAC (or 20 business days for any re-submission) with an “Affirmed” or “Non-Affirmed” decision letter sent to the agency by mail, fax, or electronic portal. The decision letter will be sent to the agency via the same method utilized for submission of the PCR request to the MAC. Decision letters for affirmed Pre-Claim Review requests will indicate a unique tracking number (UTN). The agency must include the UTN on the final claim. If a final claim is submitted without a UTN, or if no Pre-Claim Review request was made prior to the submission of the final claim, the MAC will hold the claim for pre-payment review. If such claims are deemed payable, then CMS will reduce payment for the episode by 25%. The Pre-Claim Review request must be submitted for each episode of care prior to submission of the final claim to avoid the 25% reduction on payable claims.
Agencies are beginning the process of adopting effective measures to ensure success and compliance with regards to these important changes. In the latest version of Alora Homecare software, we are incorporating new tools to help meet the Pre-Claim Review requirements for agencies located in the affected states.
At your convenience, you may visit the following links for more information on the Pre-Claim Review Demonstration and requirements for submission
For more information on this topic or on Software for Medicare Pre-Claim Review, email us at Info@Alorahealth.com
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