5 Things You Need to Know about Pre-Claim Review

The Centers for Medicare & Medicaid Services' (CMS) Pre-Claim Review Demonstration rolls out in 5 states beginning on August 1, 2016. If you are like many home health agencies, you may be nervous about how this change will affect your business.

UPDATE: CMS announced on May 31, 2018 that it was revisiting the Home Health Pre-claim Review Demonstration in an expanded way. We discuss in our new blog post: Getting Ready for Pre-Claim Review (again): Steps to Success


What is the Pre-Claim REview Demonstration?

Pre-Claim Review is a review process managed by Medicare Administrative Contractors (MACs) prior to a final reimbursement. Home health agencies will request a provisional affirmation of coverage before a final claim is submitted for payment. Submission and affirmation of pre-claims confirms that all certification and coverage requirements are met. By enacting this pilot program, CMS hopes to reduce fraud while maintaining or improving the quality of care to Medicare beneficiaries.


Pre-claim Review does not require any additional documentation. This new step requires that the same documentation be presented - just earlier in the process. Agencies can adapt to this new step by ensuring that they have simple, automated and systematic document management practices in place.



The Pre-claim Review currently affects Home Health Agencies in five states. The initial three-year pre-claim review demonstration begins in Illinois on August 1, 2016 and then will roll out to Florida, Texas, Michigan and Massachusetts.

  • Illinois - August 1, 2016 - Paused 

  • Florida - October 1, 2016 - April 1, 2017 - Delayed

  • Texas - December 1, 2016 - Delayed

  • Michigan - January 1, 2017 - Delayed

  • Massachusetts - January 1, 2017 - Delayed

Low Utilization Payment Adjustment (LUPAs) do not require the submission of a pre-claim.


How does Pre-Claim Review Affect my organization?

While submission is voluntary, failure to submit and receive affirmation of a pre-claim prior to submitting a final claim will result in a 25% decrease in payment. This 25% reduction cannot be appealed. To avoid it, be sure to submit (an re-submit if not affirmed) the pre-claim, prior to submitting the final claim.


WHAT CAN I Do to Prepare for Pre-CLaim Review Demonstration?

Review your current document management processes. A full list of the required documents can be found on pages 8 and 9 here. Organized and efficient workflows paired with strict follow-up procedures are going to be more important now than ever before.

  • Intake and Referral Management: develop concise, but thorough workflows to process referrals and other inbound documents faster.

  • 485 & Orders Tracking: streamline outbound delivery and increase follow-up to improve document turnaround time.

  • Face to Face Encounters: implement a standard process is for completing F2Fs accurately and timely.

  • Pre-Claim Submission: decide who will be responsible for submitting and re-submitting pre-claims. They'll need quick access to all required documentation and billing information.

Your organization's people, process, and technology are critical to seamless implementation of new programs like this. Talk to your team about who will be doing what and research tools that can help streamline the process.


WHAT Should I do If I have Questions or concerns About the Pre-Claim Review Process?

☑ Visit the CMS website

☑ Reach out to your MAC (Palmetto, NGS, or CGS)

☑ Contact Forcura

Sources: https://www.cms.gov/http://www.palmettogba.com/http://homehealthcarenews.com/

Topics: CMS Regulatory Guidance

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