Pre-Claim Review Demonstration to Expand to Florida in April 2017

Update: On March 31, 2017, CMS stated that the Pre-Claim Review Demonstration will not expand to Florida on April 1, 2017 as planned. CMS will notify providers at least 30 days in advance via an update on their website of further developments related to the demonstration. HEALTHCAREfirst will continue to monitor the status and provide updates as information is made available.

On December 19, 2016 CMS announced that it will expand the Home Health Pre-Claim Review Demonstration to Florida for services that begin on or after April 1, 2017. While no further information was provided, CMS did say that the Medicare Administrative Contractors (MACs) would continue outreach in Florida to ensure that home health agencies in Florida are ready.

What is pre-claim review?

Pre-claim review is a process by which a request for coverage is submitted for review before a final claim is submitted for payment. Pre-claim review requests are made any time after initial assessments and intake procedures are complete, but before the final claim is submitted.

What is the timeline for Medicare to affirm or non-affirm pre-claim review requests?

CMS has stated that pre-claim review requests will be affirmed within or around ten business days following an initial request and 20 business days following a resubmitted request initiated as a result of a non-affirmed decision.

What are the penalties for non-compliance?

After the first three months of demonstration in a particular state, a 25% payment reduction will be applied for claims that, after such pre-payment review, are found to be payable, but did not first receive a pre-claim review decision prior to final claim submission.

Want to learn more about the Pre-Claim Review Demonstration? Download “A Guide to the Pre-Claim Review Process” from HEALTHCAREfirst.

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