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March 14, 2013

2013 Therapy Cap Process

For dates of service January 1, 2013 through December 31, 2013, all outpatient therapy claims submitted above the $3,700 threshold will be subject to prepayment medical review. CGS will send Additional Documentation Requests (ADRs) for all claims above the $3,700 threshold. In these ADRs, CGS will request the following documentation:

  • Justification;
  • Evaluation or reevaluation(s) for Plan(s) or Care;
  • Certification of the Plan of Care;
  • Objectives and measurable goals and any other documentation requirements of the Local Coverage Determination (LCDs) (note: objectives and goals should also include an estimation of reasonable time frame in which the patient could be expected to achieve the stated goals);
  • Progress reports;
  • Treatment notes;
  • Certification or recertification for therapy services;
  • Any orders, if applicable, for additional therapy services; and
  • Any additional information requested by CGS.

Follow the instructions provided on the ADRs when sending documentation.

**To the extent possible, CGS will complete the prepayment review of therapy claims within 10 business days from the date we receive the requested records. If we cannot review the claims within 10 business days of the date of receipt, we will complete the review within the 60 day medical review timeframe as mandated by the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section

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