Breaking News: CMS expands Home Health Pre-Claim Review program to Florida, starting April 2017

The Centers for Medicare & Medicaid Services (CMS) announced on Dec. 19, 2016, that it will expand the Pre-Claim Review Demonstration for Home Health Services to Florida for episodes of care that begin on or after April 1, 2017. Additional education has been provided by CMS on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation decisions. Medicare Administrative Contractors are continuing educational outreach in Florida to ensure that providers are informed. See the Dec.19 fact sheet release from CMS for more details.

StatePre-Claim Review Begins For Episodes With Start Dates On or After
IllinoisStarted on August 3, 2016
FloridaWill begin April 1, 2017

Status of other states

CMS announced on Sept. 19, 2016, that there would be a delay in the expansion of the home health pre-claim review program that was launched in Illinois.

On Dec. 19 CMS continued the expansion with Florida, with an effective date of April 1, 2017. Other states will follow with staggered start dates.

The states of Texas, Michigan, and Massachusetts (which were previously scheduled to enact expansions by Jan. 1, 2017) do not yet have specified start dates. CMS will provide at least a 30-day notice on their website prior to expansion for these states.

This phasing will allow CMS time to provide home health agencies additional education to assist with the pre-claim review submission process, required documentation, and common reasons agencies might receive a non-affirmed response.

CMS previously announced in June the pre-claim review program for home health services, which aims to crack down on Medicare fraud and abuse. The state of Illinois was the first participant (August 3, 2016) and continues in the program.

Top 5 Things You Need To Know About Home Health Pre-Claim Review

  1. Home health providers are required to obtain a pre-claim review for home health services prior to submission of a final claim.
  2. The pre-claim review demonstration does not create new documentation requirements, according to CMS.
  3. Affirmative decisions on pre-claim reviews will be issued a Unique Tracking Number (UTN) that must be included when submitting the final claim to be eligible for payment.
  4. Claims submitted without a pre-claim review decision can reduce payment amounts and/or lengthen revenue cycle time.
  5. After 3 months, claims submitted without a pre-claim review decision will be paid with a 25% reduction of the full claim amount. This decision cannot be appealed.

Home Health Pre-Claim Request Coversheet for Manual Submissions

Included below is a template to help simplify and standardize the data elements portion of the pre-claim review request package. This document can be used as a coversheet and checklist when manually submitting a pre-claim review by fax or mail to help ensure that all the proper information has been included.

CMS Pre-Claim Review Information Sheet

The information sheet below will provide you with “at a glance” information on the requirements, including links to important CMS websites about the demonstration.

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