Home Health & Hospice Week

MACs will have 10 business days to issue a decision under demo.

With CMS intimating it would like to expand its “pre-claim review demonstration” sooner rather than later, the operational details are important to all home health agencies — not just those in the five demo states.

Step 1: Submit a Request for Anticipated payment and begin providing services as usual.

Step 2: Under the program, all HHAs in the demo states would submit a pre-claim review request to their Medicare Administrative Contractor that contains “all relevant documentation to support Medicare coverage of the applicable home health level of service,” according to the notice scheduled for publication in the June 10 Federal Register.

Question: The notice isn’t specific about what exact documents would be required of agencies in the pre-claim request, notes Chicago-based regulatory consultant Rebecca Friedman Zuber. It appears that may be up to the MACs.

Step 3: “After receipt of all relevant documentation, the MAC will review the pre-claim review request to determine whether the service level complies with applicable Medicare coverage and clinical documentation requirements,” CMS explains in the notice.

Step 4: “The MAC will make all reasonable efforts to make a determination and issue a notice of the decision within 10 business days,” CMS says. The timeline eases to 20 days for resubmissions.

Step 5: If the MAC “declines payment,” HHAs can resubmit the request with missing documentation or submit the claim and pursue an appeal when it’s denied.

If the MAC approves payment, HHAs will submit the final claim with a tracking number indicating the claim “has been affirmed for pre-claim review,” CMS explains.

Alternate route: If agencies fail to submit a claim for pre-claim review, it won’t result in an automatic denial. Upon submission, the claim will be stopped for prepay review with a documentation request. “After the first 3 months of the demonstration, we will reduce payment by 25 percent for claims that after such prepayment review are deemed payable but did not first receive a pre-claim review decision,” CMS says in the notice.

Note: More information about the demo, including a fact sheet and Frequently Asked Question set, is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html.