CorporateBusiness Services

Pre-Claim Review Demonstration for Home Health Services

Update: 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. Refer to the CMS Pre-Claim Review Demonstration for Home Health ServicesExternal Website Web page for additional information.

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, §30.5.1.1External PDFfor information on home health coverage criteria. For additional information on the home health PCR program, visit the Pre-Claim Review Demonstration for Home Health ServicesExternal Website information and the Pre-Claim Review Demonstration for Home Health Services Operational GuideExternal PDF 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. To check to see if your home health agency is part of the PCR demonstration, refer to the CGS Home Health Pre-Claim Review Demonstration Look-Up Tool.

State Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN) – State Codes Start Date (for episodes with a start date on or after) Two Weeks Prior
Illinois 14 and 78 August 3, 2016 Paused as of April 1, 2017
Florida 10, 68 and 69 TBD TBD
Texas 45, 67, 74, and 97 TBD
but no earlier than
December 1, 2016
TBD
Massachusetts 22 and 82 TBD but no earlier than
January 1, 2017
TBD
Michigan 23 TBD but no earlier than
January 1, 2017
TBD

Refer to the Certification Number (CCN) State Codes MemorandumExternal PDF 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.

Back to the top of the page Top

Step 1 – Submit RAP

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 10.1.10.3External PDF).

A PCR request must be submitted for each 60-day episode.

Back to the top of the page Top

Step 2 – Complete/Submit PCR Coversheet and Documentation

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) CoversheetPDF (temporarily unavailable) 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.

  • Certification and/or Recertification
  • Face-to-Face visit note
  • Acute/post-acute care visit notes
  • Home health plan of care (signed and dated)
  • Therapy evaluations
  • Outcome and Assessment Information Set (OASIS)
  • Initial orders

The following type of bills (TOBs) and HCPCS codes are part of this PCR program:

TOBs

  • 327 – Replacement of prior claim
  • 329 – Final claim for home health episode
  • 32Q – Reopening request

The following TOBs apply to adjustments initiated by CGS.

32F 32G 32H 32I 32J 32K 32M 32P

HCPCS (codes subject to change)

Skilled Nursing G0162, G0163, G0164, G0299, G0300, G0493, G0494, G0495, G0496

NOTE: G0163 and G0164 are not valid for visits on or after January 1, 2017. HCPCS codes G0493, G0494, G0495, G0496 are valid for visits on or after January 1, 2017.
Physical Therapy G0151, G0157, G0159
Occupational Therapy G0152, G0158, G0160
Speech-language Pathologist G0153, G0161
Social Worker G0155
Aide G0156

How to Submit: The PCR Coversheet and documentation can be submitted via :

  • Fax 615.664.5950
  • myCGS Web Portal – Refer to Chapter 7: Forms TabPDFof the myCGS User Guide for details. For more information about myCGS and how to register, refer to the Chapter 1: Overview of myCGSPDF of the myCGS User Guide.

    NOTE: For PCRs submitted via myCGS, the PCR decision notification letter (provisionally affirm or non-affirm) will be sent to home health providers via mail or fax. When submitting a PCR request, via myCGS, please provide your fax number in the space indicated on the PCR Coversheet.  If no fax information is provided, CGS will mail the PCR decision notification letter to the provider.

  • esMD (Electronic Submission of Medical Documentation) – Refer to the CMS "Information for ProvidersExternal Website" Web page for details.
  • Mail:

    CGS Administrators
    PO Box 20203
    Nashville, TN 37202

Future enhancements are planned which will allow submission via Electronic Submission of Medical Documentation (esMD).

Back to the top of the page Top

Step 3 – Medical Review of Documentation and Decision Notification

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).

  • Affirm decisions mean that Medicare coverage, coding, and payment requirements have been met.
  • Non-affirm decisions mean that the submitted documentation did not meet Medicare requirements for coverage.
    • Non-affirmed decisions are considered an initial payment decision and the standard claims appeal rights apply. Refer to the "Appeals Overview" Web page for additional information.
  • Resubmitted PCR Requests
    • An unlimited number of resubmissions are allowed. Refer to Step 4 (below) for information about resubmitted PCR requests.
  • Unique Track Number (UTN)
    • The decision letter (affirm and non-affirm) will include a 14 digit Unique Tracking Number (UTN), which must be submitted on the final claim.

Back to the top of the page Top

Step 4 (Conditional) - Resubmitting PCR Requests

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.

Back to the top of the page Top

Step 5 – Submit Final Claim

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.

  • ASC X12 837 5010 – Positions 19 through 32 of Loop 2300 REF02 (REF01=G1)
  • CMS-1450 (UB-04) – Form Locator 63 (positions 19-30). The last two characters of the UTN should be written outside the lines next to position 30.
  • Direct Data Entry – TREAT. AUTH. CODE field immediately following the 18-digit OASIS Matching Key code (example below).

    Screenshot

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.

Back to the top of the page Top

Additional Resources:

Back to the top of the page Top

Updated 04.03.17


Two Vantage Way, Nashville, TN 37228 ©2017 CGS Administrators, LLC. All Rights Reserved