Clearing the Centers for Medicare & Medicaid Services (CMS) Pre-Claim Review Process – Here’s What You Got To Do

Pre-Claim Review is review process that is managed by MACs (Medicare Administrative Contractors) before a final reimbursement is made. Under this, home health agencies submit a provisional approval for coverage before the final claim is filed. Submission and subsequent approval of pre-claims confirm that all the necessary requirements and documentation are in order. This is a pilot program, through which CMS hopes to bring down the number of fraudulent cases, while also improve the quality of services and facilities provided to the Medicare beneficiaries.

CMS made an announcement awhile back that it will hold demonstrations for Medicare pre-claim review for home health agencies in 5 states. The demonstration for home health services started officially in Illinois on August 3rd, 2016. The dates for the remaining 4 states, Florida, Massachusetts, Michigan and Texas is likely to be pushed ahead, primarily because the state of Illinois is already facing undue hardship since the implementation. The home health agencies (or HHAs) in the state have been a sked not to submit review requests for pre-claims related to the cases that began before August 3, 2016.

Preparing for Pre-Claim Review Demonstration

To begin with, you must review all of your current processes for document management. The complete list of required documents include:

  • Beneficiary information, including name, date of birth and Medicare number
  • Certified practitioner information, including name, address, national provider identifier and PTAN
  • HHA information, including agency’s name, national provider identifier, PTAN, address and CMS certification number
  • Submitter information when applicable, including name and contact number
  • Details for other information, such as benefit period requested, state where service is rendered, submission date, review stage, or more
  • Documentation from the medical records which states whether the person is:
  • Confined within the home premises
  • Under direct care of a physician
  • Needs services of a skilled practitioner
  • Has to undergo mandatory visit to the Medicare personnel as per the Affordable Care Act

Next, you must prepare for the subsequent stages, which are:

  1. Intake & Referral Management: You have to develop concise yet thorough workflows for processing referrals and all other inbound documents at the earliest.
  2. 485 and Order Tracking: Work around to streamline outbound delivery and also follow up more to bring down document turnaround time.
  3. Face to Face Encounters: You will have to implement a standard process that will help you pass face to face meetings timely and with precision.
  4. Pre-Claim Submission: You will need to determine the person who will submit/resubmit pre-claims. The person will also have quick access to the essential documentation as well as billing information.

For more information about the pre-claim review process, join Arlene Maxim in a webinar, titled ‘CMS Pre Claim Review – Curse or Cure?’. During the session, you will receive a Mac’s work flow copy, sharing advice for steps to follow before submission. She will also share up-to-date information from different agencies based in Illinois and how they deal with the CMS pre-claim review rule.

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