CMS Issues Pre-Claim Review Demonstration Operational Guide
June 27, 2016 07:01 PM
The Centers for Medicare & Medicaid Services (CMS) has issued the Pre-Claim Review Demonstration for Home Health Services Operational Guide. CMS had planned to issue the guide by June 28.
The Operational Guide does not provide much more information regarding the Pre-Claim Review Demonstration than what CMS has already communicated to providers through their fact sheet, a Special Open Door Forum (SODF) call (see NAHC report), and the frequently asked questions (FAQs). During the SODF call, CMS stated that the Operational Guide would be a draft and open to public comment. The document appears to be a final version.
The document is 24 pages long, covers 11 subject areas and includes 4 appendices that diagram the pre-claim review request submission process and claim submissions with and without a pre-claim review.
The Pre-Claim Review Demonstration is a three year project that applies to all home health agencies in Illinois, Florida, Texas, Michigan, and Massachusetts.
Under the demonstration,the agency will submit a pre-claim review request to receive a determination regarding eligibility and coverage before submitting a claim.The contractor will review the pre-claim review request to determine whether the services meet applicable Medicare eligibility and coverage criteria. For initial reviews, a determination is to be issued within 10 business days, for subsequent reviews within 20 days.
As stated on the June 14, Special Open door Forum, CMS outlines in the Operational Guide specific information to be listed on the Pre-Claim Review request. Documentation to support eligibility and coverage for home health services must also be submitted. However, CMS does not specify what documentation needs to be submitted nor do they provide guidance regarding acceptable documentation to support eligibility and coverage to assure affirmation of payment.
Once a payment decision has been made, the agency will receive notice of the determination along with a unique tracking number (UTN) that must be placed on the final claim.
CMS states in the Operation Guide, as they did on the SODF, that for submission of a claim on a CMS-UB04 Claim Form, the UTN will be in field locator 63. For submission of electronic claims, the UTN must be submitted following the OASIS assessment data (Positions 1-18) in positions 19 through 32 of loop 2300 REF02 (REF01=G1). This claim location for the UTN originally raised concern since it is the same location for home health Treatment Authorization Code.
If a claim is submitted without a UTN the claim will be subject to a 25 % reduction in payment. CMS is providing a 3-month grace period from the 25% reduction beginning from the time the demonstration is initiated in each state.
CMS has also revised the FAQs document for the Home Health Pre–Claim Review Demonstration and added several new questions and answers.
A second Special Open Door Forum call on the home health Pre-Claim Review Demonstration is scheduled for June 28.