Breaking News: CMS suspends Pre-Claim Review

The Centers for Medicare & Medicaid Services (CMS) announced on March 31 that it has suspended the Pre-Claim Review demonstration program (PCR).  The announcement states:

“As of April 1, 2017, the Pre-Claim Review demonstration will be paused for at least 30 days in Illinois. The demonstration will not expand to Florida on April 1, 2017.

“After March 31, 2017, and continuing throughout the pause, the Medicare Administrative Contractors will not accept any Pre-Claim Review requests.  During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration.”

Read the March 31 announcement from CMS here.

ABILITY responds: Home Health Pre-Claim Review

The Centers for Medicare & Medicaid Services (CMS) implemented the Pre-Claim Review (PCR) mandate last year. At this time, PCR’s future is still uncertain and new legislation could bring rapid changes. ABILITY is moving forward to ensure we have a comprehensive electronic solution for our customers. In the meantime, you should keep in mind two important points:

  1. ABILITY has developed the customer-facing application to respond to PCR, and we are now working with the MACs to establish connectivity with their system. We will be able to submit pre-claim review electronically and receive review decisions from the MACs elelctronically as well. The MACs are still in early adopter phase for this and – outside of a very small pilot – have not enabled access to vendors for submission. Our strong relationships with the MACs and CMS will ensure that the final version of our application will cover all the bases for you.
  2. We recommend that you pre-order now to be placed on the list for the new ABILITY PCR application. There’s no cost to you at this point; simply fill out the form at the right and once our application is ready, we’ll give you a call to give you a full demonstration. By securing your place on the list, you ensure that you’ll be able to very quickly implement a smoother, more streamlined workflow.

Whether your state has already implemented PCR or if you’re trying to improve your current claims workflow, ABILITY can help.

Pre-Claim Review implementation: where it stands

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.

Illinois was the first state to implement PCR; Texas, Michigan and Massachusetts are currently in line to implement after Florida, although they have not yet been scheduled.

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

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.

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