Stay Ahead During Pre-Claim Review Demonstration


At Forcura, we believe that there are three areas to consider to smoothly implement a new technology solution or adapt to a new regulation: people, process and technology.

With CMS’ Pre-Claim Review Demonstration underway, now is the time to review and streamline your infrastructure and processes to ensure efficiency, timeliness, and accuracy.

Below, we’ve outlined exactly which questions you need to answer for your organization to manage pre-claim review and ensure your cash flow is not adversely affected. Formulating a plan now will result in avoided reimbursement reductions, efficiency gains, improved cash flow, and reduced expenses later.



Who is doing what? A smooth pre-claim request submission process will require collaboration from multiple departments. Here are some questions to ask regarding your team:

  • Who is on point to manage your pre-claim review process?
  • Who is tracking the documents required for the pre-claim request?
  • Who will organize the pre-claim request documentation prior to submission?
  • Who will review the pre-claim request for accuracy?
  • Who will submit the pre-claim request?
  • Who submits the final claim?
  • Do you need to hire additional staff or will process and technology improvements prevent added FTE costs?

Accuracy and speedy submission will rely on the people who manage the pre-claim requests. Make sure you have the right people doing each task related to the pre-claim review, from intake to tracking orders to billing. Once you’ve determined your team, you’ll need a clear concise process.



Pre-Claim Review is new for everyone. Failure to develop a dedicated process can result in reduced reimbursement. You’ll need to create a pre-claim approval, tracking, and submission process to ensure you can maintain your cash flow.

  • How are you preparing your staff, referral sources, and signing physicians for this change?
  • What are your processes for managing referrals, face-to-face encounters, and 485s?
  • If the pre-claim and final claim are not submitted by the same person/ team, how are the different parties communicating?
  • At what point are you submitting the pre-claim request?
  • How are you tracking pre-claim requests awaiting an affirmed or non-affirmed decision?
  • How will you organize required documents, so you can easily resubmit them?

Streamlined submission, tracking, review, and billing processes are dependent on technology you are using. We recommend creating dedicated workflows with the right tools.



E-submit is the preferred submission method with the fastest turnaround time. Whether you’re submitting this way or via mail or fax, you’ll want electronic copies of all documentation readily available.

  • What technology is being used to track the required documentation?
  • How are you submitting pre-claim requests? Mail, fax, or e-submit?
  • Is the required documentation easily available in electronic form?
  • What tools are you using to follow up on outstanding documentation?
  • Are the tools you’re using to collaborate and communicate secure and HIPAA-compliant?

Tools like Forcura, allow your team to track required documents like referrals, face-to-face encounters, and 485s electronically from any location. Custom workflows provide an easy way for your intake, medical records, and billing teams to collaborate and process documents in a fraction of the time. 


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We are working with many of our clients to help them through the adoption of pre-claim review. Contact us to learn how we can help you.

Topics: CMS Regulatory Guidance

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