Prior Authorization and Pre-Claim Review Initiatives: Pre-Claim Review Demonstration for Home Health Services

05/30/2018 Updates

On April 1, 2017, the Pre-Claim Review Demonstration for Home Health Services was paused in Illinois and was not expanded to other states.  Following the pause, CMS worked to revise the Demonstration to incorporate more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies. More information on the revised Review Choice Demonstration for Home Health Services can be found here.

04/28 Updates

Please see the updated Questions and Answers document in the Downloads section below for additional information on the Pre-claim Review demonstration pause.

03/31 Updates

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.   

After March 31, 2017, and continuing throughout the pause, the Medicare Administrative Contractors will not accept any Pre-Claim Review requests.  During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration.

01/20 Updates

Provisional Affirmation Rate Update

As of Week 24 of the Demonstration, which ended on 1/14/2017, 91.7 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.  In our effort to provide transparency with respect to the affirmation rate, CMS has provided a breakdown of fully affirmed decisions and partially affirmed decisions through Week 24.  Refer to the document “Week Twenty Four Affirm Rate in Illinois” in the “Downloads” section below for more information.

Partner Tip Sheet

CMS has developed a Partner Tip Sheet with information partners can use on the Medicare Fee-for-Service: Pre-Claim Review Demonstration for Home Health Services.  This Partner Tip Sheet includes general information on the Demonstration and provides contacts for further information.  Refer to the document “ Medicare-Fee-for-Service: Per-Claim Review Demonstration for Home Health Services”  in the “Downloads” section below to see the information.

Updated Frequently Asked Questions

CMS has updated the Frequently Asked Questions (FAQs) for the Demonstration. Refer to the document “Pre-Claim-Review-Frequently-Asked-Questions 1_20_17” in the “Downloads” section below.

01/06 Updates

As of Week 22 of the Demonstration, which ended on 12/31/2016, 90.8 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.  In our effort to provide transparency with respect to the affirmation rate, CMS has provided a breakdown of fully affirmed decisions and partially affirmed decisions through Week 22.  Refer to the document “Week Twenty Two Affirm Rate in Illinois” in the “Downloads” section below for more information.

01/03 Updates

The slide presentation for the Special Open Door Forum: Law-Enforcement Observations About Home-Health Fraud, on Wednesday, January 4, 2017, can be found in the downloads section below. For more information on this Special Open Door Forum, please see the full announcement here. (PDF)

12/22 Updates

As of Week 20 of the Demonstration, which ended on 12/17/2016, 89.4 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.  In our effort to provide transparency with respect to the affirmation rate, CMS has provided a breakdown of fully affirmed decisions and partially affirmed decisions through Week 20.  Refer to the document “Week Twenty Affirm Rate in Illinois” in the “Downloads” section below for more information.

12/19 Updates

Notice for Expansion of the Pre-Claim Review Demonstration for Home Health Services to Florida

CMS will expand the Pre-Claim Review Demonstration for Home Health Services to Florida for services that begin on or after April 1, 2017.  CMS and the Medicare Administrative Contractors have provided education to impacted providers on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation decisions.  The Medicare Administrative Contractors will continue to conduct outreach in Florida.   

12/09 Updates

As of Week 18 of the Demonstration, which ended on 12/03/2016, 87.1 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.  In our effort to provide transparency with respect to the affirmation rate, CMS has provided a breakdown of fully affirmed decisions and partially affirmed decisions through Week 18.  Refer to the document “Week Eighteen Affirm Rate in Illinois” in the “Downloads” section below for more information.

12/02 Updates

Provisional Affirmation Rate Update

As of Week 17, which ended on 11/26/2016, 87 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.  In a continuing effort to provide transparency with respect to the affirmation rate, CMS is providing the breakdown of fully affirmed decisions and partially affirmed decisions.  In Week 17, 83 percent of pre-claim review requests received a fully affirmed decision, and 4 percent received a partially affirmed decision.  A partially affirmed decision indicates at least one service submitted on the pre-claim review request was provisionally affirmed and at least one service was non-affirmed.  For example, a pre-claim review request may be submitted for skilled nursing services, physical therapy, and speech therapy.  However, only the skilled nursing services and physical therapy are provisionally affirmed, while the speech therapy is non-affirmed.  This would result in a partially affirmed decision.  If a submitter receives a partially affirmed decision, he or she has 2 options:

1. Take no further action.  Submit a claim for all provisionally affirmed and non-affirmed services.  All provisionally affirmed services will be paid as long as all Medicare requirements are met.  All non-affirmed services will be denied.
2. Resubmit a request with additional documentation to support the non-affirmed services.  After receiving a provisionally affirmed decision for all services, submit a claim.  All services will be paid  as long as all Medicare requirements are met and off-limits* for MAC, RAC or SMRC review.Refer to the document “Week Seventeen Affirm Rate in Illinois” in the “Downloads” section below for more information.
3.       *absent evidence of gaming or potential fraud.

11/18 Updates

Variation in Home Health Agency (HHA) Provisional Affirmation Rates Update:

The percentage of pre-claim review requests in Illinois receiving a provisional affirmation decision, including both fully affirmed or partially affirmed decisions, has increased as the demonstration continues.  CMS has seen a wide variation in the provisional affirmation rates among individual HHAs.  CMS is releasing an updated graph showing the number of HHAs in Illinois that have various affirmation rates for the pre-claim review requests they have submitted/resubmitted thru 10/29/16 now using a cumulative methodology.  As experience with submitting pre-claim review requests increases and additional education, such as proactive outreach to HHAs receiving non-affirmed decisions, is conducted, more HHAs are increasing their affirmation rate.  See the document called “Number of HHAs by Affirm Rate in Illinois 11-18-16” in the “Downloads” section below for more information.

Comparing Decisions to Affirm Rates:

The percentage of provisionally affirmed decisions received, including both fully and partially affirmed decisions, varies amongst Home Health Agencies (HHAs) in Illinois.  Looking at decisions made through 10/29/16, CMS has seen that HHAs who have received more decisions generally have a higher affirmation rate.  There is a strong correlation between the number of submissions sent by a HHA and the number of provisionally affirmed decisions received.  The average provisional affirmation rate of all HHAs combined who had at least 10 decisions was 81%.  The average provisional affirmation rate of all  HHAs combined with fewer than 10 decisions was 62%.  See the document called “Comparing PCRD Decisions to Affirm Rates 11-18-16” in the “Downloads” section below for more information

Reason Codes

The latest Review Reason Statements for the Pre-Claim Review Demonstration for Home Health Services are available in the “Downloads” section below. CMS plans to provide monthly updates of these Review Reason Statements and welcomes any feedback or comments regarding them.  All feedback or comments should be sent to ReviewStatements@cms.hhs.gov.

Updated Frequently Asked Questions

On 11/17/2016, The Centers for Medicare & Medicaid Services (CMS) updated the Frequently Asked Questions (FAQs) for the Pre-Claim Review Demonstration for Home Health Services. Please see the attached FAQs in the “Downloads” section below.

Provisional Affirmation Rate Update

As of Week 14, which ended on 11/5/2016, 82 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.  In an effort to provide further transparency with respect to the affirmation rate, CMS is providing the breakdown of fully affirmed decisions and partially affirmed decisions.  In Week 14, 77 percent of pre-claim review requests received a fully affirmed decision, and 5 percent received a partially affirmed decision.  A partially affirmed decision indicates at least one service submitted on the pre-claim review request was provisionally affirmed and at least one service was non-affirmed.  For example, a pre-claim review request may be submitted for skilled nursing services, physical therapy, and speech therapy.  However, only the skilled nursing services and physical therapy are provisionally affirmed, while the speech therapy is non-affirmed.  This would result in a partially affirmed decision.  If a submitter receives a partially affirmed decision, he or she has 2 options:

1. Take no further action.  Submit a claim for all provisionally affirmed and non-affirmed services.  All provisionally affirmed services will be paid as long as all Medicare requirements are met.  All non-affirmed services will be denied.
2. Resubmit a request with additional documentation to support the non-affirmed services.  After receiving a provisionally affirmed decision for all services, submit a claim.  All services will be paid  as long as all Medicare requirements are met and off-limits* for MAC, RAC or SMRC review.

      *absent evidence of gaming or potential fraud.

As of Week 13 which ended on 10/29/2016, 83 percent of pre-claim review requests in Illinois received an affirmed or partially affirmed decision.   Refer to the document “Week Thirteen Affirm Rate in Illinois” in the “Downloads” section below for more information.

10/27 Updates

Updated Frequently Asked Questions

On 10/27/2016, CMS updated the Frequently Asked Questions (FAQs) for the Pre-Claim Review Demonstration for Home Health Services.  Please see the “Downloads” section below for the updated FAQs.  There is a reference in Question 65 of the FAQs to an example.  That example is also located in the downloads section, “FAQ # 65 HH Cert and Plan of Care example”. 

 10/21 Updates

Affirmation Rate Continues to Increase in Illinois

As of Week 11 which ended on 10/15/2016, 78 percent of pre-claim review requests in Illinois received an affirmed or partially affirmed decision.   Refer to the document “Week Eleven Affirm Rate in Illinois” in the “Downloads” section below for more information. 

Variation in Home Health Agency (HHA) Affirm Rates

As of week 11 which ended on 10/15/2016, we are seeing wide variation in the affirm rates of HHAs.  Some HHAs have a 100 percent affirm rate and some have a 0 percent affirm rate.  Many HHAs lie somewhere in the middle.  See the document called “Number of HHAs by Affirm Rate in Illinois” in the “Downloads” section below for more information.

New Process Being Implemented with Our Medicare Review Contractors

We are trying to distinguish between those beneficiaries who are not eligible for Medicare covered home health services and those that may be eligible but the documentation is lacking in some way.  CMS has initiated a new process with our review contractors to help identify those individuals who should qualify for the Medicare benefit and provide direct education to the HHA to guide them on what is needed to get an affirmed decision.  See the attached “Process Diagram” in the “Downloads” section below for more information. 

Note on Submitting Pre-Claim Review Requests through Palmetto GBA’s eService Portal

When submitting a pre-claim review request through Palmetto GBA’s eService portal, submitters do not need to attach the same document multiple times.  If one document can support more than one task, submitters may upload the attachment for the first task.  Then in the comment box for any other tasks the document supports, the submitter should put a comment referencing the location of the information in the previously attached document.  More information can be found on the Palmetto GBA website at www.PalmettoGBA.com/PCR.

Updated Frequently Asked Questions

On 10/21/2016, The Centers for Medicare & Medicaid Services (CMS) updated the Frequently Asked Questions (FAQs) for the Pre-Claim Review Demonstration for Home Health Services.  Question 62 references a new Review Decision Flowchart.  Please see the “Downloads” section below for the updated FAQs and the “Review Decision Flow Chart”. 

Reason Codes

The latest Review Reason Statements for the Pre-Claim Review Demonstration for Home Health Services are available in the “Downloads” section below. CMS plans to provide monthly updates of these Review Reason Statements and welcomes any feedback or comments regarding them.  All feedback or comments should be sent to ReviewStatements@cms.hhs.gov.

10/5 Updates

Early Data from Illinois

CMS has seen significant interest in the Pre-Claim Review Demonstration (PCRD) for Home Health Services and is releasing early statistics based on the initial data from Illinois.  Please see the PCRD IL Data Fact Sheet in the “Downloads” section below. 

Update on Expansion of Pre-Claim Review Demonstration for Home Health Services

The Pre-Claim Review Demonstration for Home Health Services began in Illinois on August 3, 2016.  Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states. Therefore, we will not move forward with initiating the demonstration in Florida in October.  The education efforts will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.     

CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states.  The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced. However, CMS will provide at least 30 days’ notice on this website prior to beginning in any state.  CMS continues to expect a staggered start, beginning with Florida. 

Pre-Claim Review Demonstration for Home Health Services Officially Began in Illinois on August 3, 2016

As the Pre-Claim Review Demonstration for Home Health Services goes into effect in Illinois, we are instructing Home Health Agencies (HHAs) in Illinois not to submit pre-claim review requests for episodes of care that began prior to August 3, 2016

In order to allow time to resolve an administrative procedural requirement related to the Paperwork Reduction Act, implementation of the Pre-Claim Review Demonstration for Home Health Services in Illinois began on August 3, 2016.  The revised start date does not impact demonstration requirements or processes, and the demonstration will be operationalized as planned for episodes of care starting on or after August 3, 2016. CMS’ Medicare Administrative Contractors will work directly with any HHAs that submitted requests for episodes of care that began prior to August 3, 2016 and allow them to either have the requests withdrawn or processed as test requests.  

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) is implementing a three-year Pre-Claim Review Demonstration for Home Health Services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017.  CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.  Additionally, CMS is testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.   

The Pre-Claim Review Demonstration for Home Health Services does not create new clinical documentation requirements. HHAs will submit the same information they currently submit for payment, but will do so earlier in the process.  This will help assure that all relevant coverage and clinical documentation requirements are met before the claim is submitted for payment.  This demonstration should not delay care to Medicare beneficiaries and does not alter the Medicare home health benefit.  The pre-claim review request may be submitted at any time before the final claim is submitted and can occur after home health services have begun.  

HHAs will begin submitting pre-claim review requests in: Illinois beginning no earlier than August 1, 2016; Florida no earlier than October 1, 2016; Texas no earlier than December 1, 2016; and Michigan and Massachusetts no earlier than January 1, 2017. This demonstration that will end in all the states on June 30, 2019.  If HHAs in the demonstration states do not utilize the pre-claim review process, those claims submitted for payment will be stopped for pre-payment review and may be subject to denial.  After the first three months of the demonstration in a participating state, CMS will reduce payment by 25 percent for claims that are deemed payable but did not first receive a pre-claim review decision.

CMS will host a second special Open Door Forum (ODF) call for HHAs, physicians, and other interested parties to learn and ask questions about the Pre-Claim Review Demonstration for Home Health Services.  The call is scheduled for 2:00 – 3:00pm ET on Tuesday, June 28, 2016.  For more information and ODF updates, visit our website at /OpenDoorForums.

For additional information please refer to the download sections below.

Questions about this demonstration may be sent to HHPreClaimDemo@cms.hhs.gov.