September 27, 2016, Pre-Claim Review Demonstration for Home Health Services Ask-the-Contractor Teleconference (ACT)
View the handoutfor the September 27, 2016, Pre-Claim Review Demonstration for Home Health Services ACT.
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- I have a question about the grace period of the 90 days where you do not get a 25% reduction. Will you then get an ADR if you do not put the Unique Tracking Number (UTN) number during this grace period time?
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During the grace period, providers in the demonstration states who do not elect to submit a Pre- Claim Review (PCR) request, will receive an Additional Development Request (ADR). If the claim is deemed payable, you will not be penalized the 25% reduction. If you do choose not to undergo the PCR process after the grace period, your claim will be ADR'd. After review, if the claim is deemed payable, it will be subject to the 25% reduction. We encourage providers to elect the PCR process.
Added: 11.07.16
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- How many affirmations, or what's your percent of affirmations you are getting, or non-affirmations?
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Please visit the CMS Pre-Claim Review Demonstration for Home Health Services Web page for affirmation statistics. Refer to the updates and download sections of this page for specific information. Per CMS, 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.
Added: 11.07.16
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- We are having a little trouble with the cover sheets that we're sending, in that it – the space is not always big enough for us to get the whole address for the doctor. In addition, it's light when we print it, it's hard to read, and we are mailing our PCRs. Can that be updated so that it is a little darker, maybe a little bigger font, and a little more room?
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The PCR Coversheet was updated in light of these concerns. There were also concerns regarding information pre-populating in various fields. This has also been addressed. The PCR Coversheet is available on the CGS website.
Added: 11.07.16
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- Do we need to send medical social worker information when we send our PCR? If we're going to have a medical social worker go out, do we need to send that as part of the PCR? Sometimes this is part of the Plan of Care and sometimes it's not.
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That's something that we don't have any specific information and guidance on, but anytime you have something that you can send in a little bit of extra information to make sure that there aren't any questions or concerns, we would encourage you to do that.
Added: 11.07.16
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- Is there an opportunity to be more specific on the reasons for the non-affirmations? They're very generic in the codes from the regulations, and sometimes it's hard to know what the issue is.
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These are the codes that have been given to us by CMS, the Centers for Medicare and Medicaid Services. Medicare Administrative Contractors (MACs) have been working with CMS to try to make those codes easier to understand and more detailed. It has helped some, because originally, one of the denial codes simply stated the face-to-face was missing, even though it was there. This really meant that if it wasn't completed the way they wanted to see it, they called it missing. We would also encourage you, any time you have a question on that, to give our customer service folks a call and see if they can help you with more explicit instructions on what's going on.
Added: 11.07.16
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- With ADRs, there is a remark section that tells you what the issue is. If you have a non-affirmation and you decide not to bill that particular service, is that okay? You just leave it off the claim? How will that work? Would that then result in an ADR?
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Since you've already gone through the process with the pre-claim review request, we suggest that you include that service on the claim with the associated UTN. Once the claim is actually processed, that service won't be paid. If you've gone through the PCR request, you shouldn't get an ADR.
Added: 11.07.16
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- I have some PCRs that I sent in August, the middle of August, and I've not received anything back on them. What's my course of action now?
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This concern was forwarded to our Medical Review Team who contacted the provider to research and resolve.
Added: 11.07.16
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- On the Medicare Secondary Payer (MSP) claim, is the 25% penalty still applicable if you do not do the PCR?
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Yes, the 25% penalty is still applicable on MSP claims that do not submit a PCR after the grace period. If the claim is deemed payable after review, it will be subject to the 25% reduction, which is already going to factor into what your MSP claim may be paid.
Added: 11.07.16
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