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By Altamash Mir

In its recent release of information pertaining to the Pre-Claim Audit, CMS has released an operational guide. This Operational Guide outlines on how the flow of documentation should be when submitting requests to MACs.
We have developed a form & a process flow chart which can be used by Home Health Agencies when submitting Pre-Claim Review Requests to their respective MACs (Medicare Administrative Contractors) scroll down

Here are some major things that all Home Health Agency Administrators must know:
• Pre-claim Authorization is needed for ALL New Patients (SOC’s) & any patients being Re-certified (Recerts) after the implementation date

• Any episodes of care beginning prior to the implementation date (August 1st, 2016 in IL) will need pre-claim authorization for the episode beginning after the implementation date, such as a Re-certification.

• Get ready for submitting requests early!!! Agencies could send pre-claim authorization requests two weeks prior to the implementation date.

• Agencies can send requests anytime between the SOC & the end of episode, but before submission of the final claim of that episode.

• Low Utilization Payment Adjustment (LUPA) episodes will not be subject to Pre-Claim Authorizations.

• Episodes that are less than 60-days will require a pre-claim review.

• Sign up for the online method of sending Pre-claim authorization requests (scroll down to get contact info for your MAC’s)

• Agencies CANNOT put patient care on hold, while waiting for Pre-claim authorization request decision! You are still held liable for a patient that has been admitted to your agency!

• The provisional approval (within 10 days) from your MAC is not transferable to another patient or agency.

• Utilize the form that we have developed to send your Pre-claim authorization requests (email to request)

Among some new requirements, CMS has outlined a few that will be completely necessary to fulfil while submitting requests for Pre-claim review:
1. Physician/Practitioner Signature on Plan of Care (Form 485)
The biggest hurdle that seems to be looming over everyone concerned is “Physician/Practitioner Signatures”.
As we all know and have gotten used to, Physicians are not so cooperative in providing much needed documentation in a timely fashion. Most of the times, the orders are faxed in late or face to face evaluations are missing crucial elements.
With the new changes in Home Health payment systems, Home Health Agencies are urged to speak with their patients and patient’s families and have them re-iterate to their Physicians the importance of timely & accurately completion of documentation. After all, Home Health Agencies will be dependent upon this documentation to be able to successfully provide quality Health Care to their patients.

2. Homebound Status
CMS has always required for any patients admitted under the Home Health Program to be homebound. As always they’ve reiterated the importance of this aspect and outlined the following conditions:
a. Patient must be Confined to Home (Homebound)
b. There exists a normal inability to leave the home and
Leaving home requires a considerable and taxing effort.
AND one of the following is true
c. a) Because of illness or injury, the person needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
d. The person has a condition such that leaving his or her home is medically contraindicated.

3. Face to Face Evaluation
The Agency must have a Face to Face Encounter Documented by the Physician/Practitioner which should:
a) Occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and
b) Be related to the primary reason the patient requires home health services; and was performed by a physician or non-physician practitioner
c) The certifying physician must also document the date of the encounter

Pre-Claim Review Request Form

request form copy
Step by Step Process for Submitting requests:
You may request Pre-Claim Review Authorization up to two weeks prior to your implementation date (example: August 1st in Illinois)

Step 1:
Receive orders from the MD to see a patient
Step 2:
Have the Physician/Practitioner provide the Agency with a Face to Face Evaluation of the patient
Step 3:
Evaluate the patient (SOC or REC) & develop a plan of care (485)
Step 4:
Have the Physician/Practitioner review & sign the plan of care
Step 5:
Review & Complete the “Pre-Claim Review Request Form” (optional)
Step 6:
Attach the required information & upload (preferred), fax or mail the information to your MAC
Step 7:
Keep a record of all claims submitted tracking sheet (email me to request a copy) & follow up on requests submitted 10 or more days ago diligently on a daily basis (optional)
Step 8:
Once a UTN (Unique Tracking Number) has been assigned to an approved claim, enter the UTN on your tracking sheet (you’ll need it at final billing). CMS has stated that they will try their best to issue the “Provisional Affirmative or Denial Decision” letters to providers within the 10 days of the submission of requests
Step 9:
Submit Final Claim upon the end of the episode with the UTN number on UTN in field locator 63 of a paper claim 1450 (UB-04), further guidelines are being awaited for Electronic Claims
Step 10:
If the Patient is being re-certified, follow steps 3-9

Non-Compliance with the Pre-Claim Review Authorization Demo
If any agency fails to send a request for pre-claim authorization & sends a final claim after providing services for an episode of treatment, the agency would have to send the required documents as they would in an ADR and the claim would not be paid automatically. Such claim might be denied based upon lack of documentation received or patient’s lack of need for home health services.

If the agency does get paid for such a claim (after submission of required documents) it will be penalized and a 25% less payment will be issued to the provider for the episode of care.

The Home Health Agency is not allowed to collect the 25% that it got paid less from the patient in any which way. The reduced payment decision cannot also be appealed either.

The 25 % payment reduction rule will not be in affect during the first 3 months of the demonstration in each state.

How to deal with Denials
If a pre-claim authorization request has been denied, the Home Health Agency may re-submit the request with the supporting documents to satisfy the requirements.

As of right now, CMS has indicated that it will notify providers of the delinquencies in documentation in the “Provisional Affirmative or Denial Decision” letters.

The MAC’s will have 20 days to review the re-submitted documentation & get back to the provider. A provider is allowed an unlimited number of resubmissions for pre-claim review requests that have not been affirmed.

For more information on how to work with denials, please review the FAQ Link at the bottom.

Home Health Agencies should send requests to their appropriate MAC.
Palmetto: (use one of the services)
a. eServices
b. esMD: (where available)
c. Fax Number: (803) 419-3263
d. Palmetto GBA – JM MAC Home Health Pre-Claim Review Mailing Address: PO Box 100232, Columbia, SC, 29202

a. eServices
b. NGS Connex
c. esMD: (where available)
d. Fax Number: MAC J6: (717)565-3840 or (315)442-4178; MAC JK (315) 442-4390
e. Mailing Address:
MAC J6: National Government Services: PO BOX 6474, Indianapolis, IN 46206-6474
MAC JK: National Government Services, Inc. P.O. Box 7108 Indianapolis, IN 46207-7108
a. Online Portal: when available
b. esMD: (where available)
c. Fax Number: (615) 664-5950
d. Mailing Address: CGS Administrators: PO Box 20203, Nashville, TN 37202


Altamash Mir
Altamash Mir
Health Care Consultant & Blogger based out of Chicago, IL.


  1. nimra says:


  2. Janette says:

    Very informative and educational! Thanks for posting!

  3. Nitasha says:

    Very informative.. it was really tough to get our employees ready for PCR in 45 days. I hope that Medicare would permanently end their rule of PCR. There are certain patients who are not able to get services because of unjustified denials from Medicare. I hope those patients will get benefit of these 30 days.

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