Pre-Claim Review Demonstration for Home Health Services
The Centers for Medicare & Medicaid Services (CMS) is implementing a three year pre-claim review (PCR) demonstration program for home health services provided to beneficiaries in Illinois, Florida, Texas, Massachusetts, and Michigan. This demonstration includes rendering providers who are located in the demonstration states regardless of from where they bill.
The PCR program ensures that the Medicare home health benefit coverage criteria are met. Refer to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7, §22.214.171.124for information on home health coverage criteria. For additional information on the home health PCR program, visit the Pre-Claim Review Demonstration for Home Health Services information and the Pre-Claim Review Demonstration for Home Health Services Operational Guide on the Centers for Medicare & Medicaid Services (CSM) website.
The start date in the following chart applies to episodes of care that begin on or after the PCR start date. A PCR must be submitted for each 60 day episode. Home health providers may begin submitting PCR requests two weeks prior to the start date. Note the receipt date for purposes of processing and timeliness is considered to be the start date of the demonstration.
Refer to the Certification Number (CCN) State Codes Memorandum for additional information about the CCN.
Note: If a final claim is submitted without a PCR request it will be stopped for pre-payment review. The provider will receive an Additional Development Request (ADR) and the CGS Medical Review will perform a pre-payment review. In addition, after the first three months from the start date of the PCR review demonstration, for each claim that does not have a PCR request submitted, a 25 percent reduction will apply to the full amount of the claim. The 25 percent reduction is not subject to appeal, and cannot be billed to the beneficiary.
Providers under Zone Program Integrity Contractors (ZPIC) review and Program Safeguard Contractors (PSC) review are not eligible to submit pre-claim review requests.
Note: The PCR program does not apply to Requests for Anticipated Payment (RAPs), Low Utilization Payment Adjustments (LUPAs), demand bills with condition code 20, and no-pay bills with condition code 21.
Refer to the four steps below detailing the PCR process.
There are no changes related to submitting the Request for Anticipated Payment (RAP), or to the RAP payment. Submit the RAP when appropriate conditions are met (Medicare Claims Processing Manual, Pub. 100-04, Ch. 10, section 10.1.10.3).
A PCR request must be submitted for each 60-day episode.
A PCR request should be submitted when you have obtained all required documentation from the medical record to support medical necessity and demonstrate eligibility requirements are met. The PCR process must occur before the final claim is submitted for payment.
Complete the Pre Claim Request (PCR) Coversheet and submit with the following supporting medical documentation.
IMPORTANT NOTE: It is important that providers complete the Pre Claim Request (PCR) Coversheet in full. List all HCPCS codes that will be submitted on the final claim.
The following type of bills (TOBs) and HCPCS codes are part of this PCR program:
The following TOBs apply to adjustments initiated by CGS.
HCPCS (codes subject to change)
How to Submit: The PCR Coversheet and documentation can be submitted via :
Future enhancements are planned which will allow submission via Electronic Submission of Medical Documentation (esMD).
CGS Medical Review staff will review the PCR request and documentation. A decision letter (provisionally affirm or non-affirm) will be sent to the HHA and the beneficiary within 10 business days of receipt for an initial request. If non-affirmed, the letter will provide a detailed explanation of the requirements not met. Refer to the Additional Resources section below to access the provisionally affirm/non-Affirm provider and beneficiary letter Job Aids.
Note: When the PCR is faxed or mailed to CGS, the decision letter will be sent in the same manner to the provider. If the PCR request is submitted via the myCGS secure web portal, at this time, the PCR decision notification letter will be sent to home health providers via mail or fax (see Step 2).
Resubmitted PCR requests may be submitted only after the previously submitted request and documentation are reviewed by Medical Review and you have received a non-affirmed decision notification letter. When a non-affirm decision is made, and based on the decision letter, additional medical documentation is available that will correct the deficiencies, a resubmitted PCR may be submitted. An unlimited number of resubmissions are allowed. A resubmitted PCR request can not be submitted after the final claim has been submitted.
The resubmitted PCR request should include the PCR Coversheet, completed in full with all the services (HCPCS) provided, and the initial documentation originally submitted and any additional documentation. Be sure to check the "Subsequent Request" check box on the PCR Coversheet.
Upon receipt, CGS will review the PCR request and documentation. A decision letter (affirm or non-affirm) will be sent to the HHA and the beneficiary within 20 business days.
Submit the final with the usual data elements. Refer to the "Home Health Claims Filing" Web page for additional information.
Note: The PCR demonstration does not apply to Requests for Anticipated Payment (RAPs), Low Utilization Payment Adjustments (LUPAs), demand bills with condition code 20, and no-pay bills with condition code 21.
In addition to the usual data elements, the 14-digit Unique Tracking Number (UTN), which is provided in the PCR decision letter, must be reported as follows.
Final claims will process based on the decision provided in the pre-claim review notification letter. If the notification letter indicated an affirm decision, the final claim will process and pay as long as all other technical and Medicare requirements are met upon claim submission. If the notification letter indicated a non-affirm decision, the final claim will be denied. Traditional appeal rights apply to non-affirmed denials.
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