Pre-Claim Review

Home health agencies (HHAs) are subject to the Review Choice Demonstration (RCD). Medicare Administrative Contractors (MACs) are required to review an HHA’s documentation to determine if beneficiaries meet home health coverage requirements per the Medicare Benefit Policy Manual, Chapter 7 (PDF).

Palmetto GBA offers HHAs a number of resources for navigating the RCD Pre-claim review process, including checklists, a video and forms.

What Is the Pre-Claim Review Option?
Pre-claim is a process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment. Pre-claim review helps make sure that applicable coverage, payment and coding rules are met before the final claim is submitted. You can find answers to frequently asked questions on the CMS website (PDF).

Certifying Physician

• Home Health Certifying Physician Documentation Video

Checklists

• Pre-Claim Review Late Period Checklist
• Pre-Claim Review Start of Care/Early Period Checklist

Centers for Medicare & Medicaid Services (CMS) Resources

• Prior Authorization and Pre-Claim Review Program Stats (PDF)

Illinois

• Urgent Pre-Claim Review Message for Illinois Home Health Providers
• 2017 Pre-Claim Review (PCR) Data for the state of Illinois

LUPAS

• Pre-Claim Review (PCR) and Low Utilization Payment Adjustments (LUPAs)

Non-Affirmations

• Pre-Claim Review Non-Affirmations: Face-to-Face Encounter
• Pre-Claim Review Non-Affirmations: Homebound
• Pre-Claim Review Non-Affirmations: Therapy

Initial Submission/Resubmission

• JM HH Pre-Claim Review Submission Request Form (PDF)

UTN

• Unique Tracking Number (UTN) Location on the Final Claim