PCRD_HH_Operational_Guide

Pre-Claim Review Demonstration for Home
Health Services
Operational Guide
Updated 07/26/2016

1

Pre-Claim Review Demonstration for Home Health Services
Operational Guide
Updated: 07/26/2016
Chapter 1:

The Home Health Benefit

Chapter 2:

Pre-Claim Review Demonstration for Home Health Services Overview

Chapter 3:

Home Health Type of Bills (TOBs) and Healthcare Common Procedure Coding
System (HCPC) Codes Subject to the Pre-Claim Review Demonstration of Home
Health Services

Chapter 4:

Number of Home Health Benefit Period 60-day Episodes of Care

Chapter 5:

Submitting a Home Health Pre-Claim Review Request

Chapter 6:

A Provisional Affirmed Decision

Chapter 7:

A Non-Affirmed Decision for Incomplete Requests

Chapter 8:

Resubmitting a Home Health Pre-Claim Review Request

Chapter 9:

Claim Submission Where Home Health Pre-Claim Review Was Sought

Chapter 10: Claim Submission Where Home Health Pre-Claim Review Was Not Sought: The
Prepayment Review Process
Chapter 11: Claim Appeals
Appendices:
A. Pre-Claim Review Request Process Example (Home Health Agency Submits)
B. Pre-Claim Review Request Process Example (Beneficiary Submits)
C. Claim Process When Pre-Claim Review Was Sought
D. Claim Process When Pre-Claim Review Was Not Sought

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Purpose
The purpose of this Operational Guide is to interpret and clarify the pre-claim review process for
Medicare participating home health agencies (HHAs) when rendering home health services for
Medicare beneficiaries. This guide will advise providers on the process for submitting
documents in support of the final claim.

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Chapter 1: Home Health Benefit
For any service to be covered by Medicare it must:
1. Be eligible for a defined Medicare benefit category;
2. Be reasonable and necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member; and
3. Meet all other applicable Medicare statutory and regulatory requirements.
To qualify for the Medicare home health benefit, under 1814(a)(2)(C) and 1835(a)(2)(A) of the
Social Security Act, a Medicare beneficiary must:
1. Be confined to the home;
o Medicare considers the person homebound if:
a) There exist a normal inability to leave the home and
b) Leaving home requires a considerable and taxing effort.
o Additionally, one of the following must also be true:
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
b) The person has a condition such that leaving his or her home is
medically contraindicated.
2. Be under the care of a physician;
3. Be receiving services under a plan of care established and periodically reviewed by a
physician;
4. Be in need of skilled services;
5. Had a face-to-face encounter with an approved
provider type. This encounter must:
• 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
• Be related to the primary reason the patient requires home health
services; and was performed by an approved provider type.
• The certifying physician must also document the date of the encounter.
For additional information on the home health face-to-face encounter requirements, see 42 CFR
424.22(a)(1)(v)(A). See Chapter 7 of the Medicare Benefit Policy for more information on the
coverage criteria for home health services.

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Chapter 2: Pre-Claim Review Demonstration of Home Health
Services Overview
Per-claim review requests may be submitted by Home Health Agencies (HHAs) that: provide
home health services, and are enrolled in the Medicare FFS program; and beneficiaries. The
term submitter will be used throughout this document to describe the person or entity that
submits the pre-claim review request.
The Pre-Claim Review Demonstration will be conducted in: Illinois, Florida, Texas, Michigan
and Massachusetts.
• Submitters may submit a pre-claim review request for each 60 day home health episode.
•

•

Submitters are encouraged to utilize the pre-claim review process for home health benefit
periods with a from date on or after:
o August 1, 2016 for HHAs located in Illinois
o TBD, but no earlier than October 1, 2016 for HHAs located in Florida
o TBD, but no earlier than December 1, 2016 for HHAs located in Texas
o TBD, but no earlier than January 1, 2017 for HHAs located in Michigan and
Massachusetts
Final claims submitted without a pre-claim review request decision will be stopped for
pre-pay review.

•

After the first three months of the demonstration in each state, if the claim is found
payable, it will be subject to a 25 percent payment reduction.

•

Providers will be able to begin submitting pre-claim requests two weeks preceding their
implementation date.

•

It is important to note that submitting a pre-claim review request is voluntary. HHAs
should place the unique tracking number (UTN) provided in the pre-claim review
decision letter on the final claim. If a non-affirmed pre-claim review decision is on file,
Medicare will deny payment for the final claim submitted for those services. This denial
will constitute an initial payment decision and the standard claims appeals process will
apply. Final claims submitted without a pre-claim review request decision will be
stopped for pre-pay review.

•

After the first three months of the start of the demonstration in each individual state, if
the claim is found payable, it will be subject to a 25 percent payment reduction. The 25
percent payment reduction is non-transferable to the beneficiary and is not subject to
appeal. While the claims will be stopped for pre-pay review, the 25 percent reduction
will not apply during the initial three months of the demonstration in each individual
state.

•

The 25 percent payment reduction is not subject to appeal and not transferable to the
beneficiary.
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Chapter 3: Home Health Type of Bills (TOBs) and Healthcare
Common Procedure Coding System (HCPCS) Codes Subject to the
Pre-Claim Review Demonstration
The following type of bills (TOBs) and healthcare common procedure coding system (HCPCS)
codes are subject to complex medical review for the demonstration:
•

•

Type of Bills (TOBs) –
o 327
o 329
o 32F
o 32G
o 32H
o 32I
o 32J
o 32K
o 32M
o 32P
o 32Q
HCPCS Codes:
o G0151
o G0152
o G0153
o G0155
o G0156
o G0157
o G0158
o G0159
o G0160
o G0161
o G0162
o G0163
o G0164
o G0299
o G0300

Important: No pre-claim review decisions will be made on a request for anticipated payment
(RAP). If a MAC receives a pre-claim review request for a RAP, the MAC will not review the
request and will not issue a decision letter.
Note: Above codes are subject to change.

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Chapter 4: Episodes of Care
•

A provisional affirmative pre-claim review decision, justified by the beneficiary’s
condition, will apply to one home health 60-day benefit period episode of care.

•

Home health services for less than 60-days will still require a pre-claim review with the
exception of a Low Utilization Payment Adjustment (LUPA).

•

A pre-claim review request must be submitted for each 60 day episode. Each claim for a
60 day episode where a pre-claim review request was not submitted, is subject to prepayment review and after the first three months in each individual state if payable, a 25
percent payment reduction.

•

Only one HHA is allowed to request pre-claim review per beneficiary per episode of
care. In a situation where a patient is discharged and readmitted to the same HHA during
the 60 day episode, a new pre-claim review request is not needed unless a separate claim
will be filed.
o See CMS IOM 100-02, Chapter 7, Section 10 for further information on what
constitutes discharge for billing and payment purposes.

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Chapter 5: Submitting a Home Health Pre-Claim Review Request
Submitters may submit a pre-claim review request at any time prior to the submission of the final
claim.
Submitters Should Include the Following Data Elements in a Home Health Pre-Claim Review
Request Package:
Beneficiary Information
• Beneficiary’s Name;
• Beneficiary’s Medicare Number (also known as HICN or MBI); and
• Beneficiary’s Date of Birth.
Certifying Physician/Practitioner Information
• Physician/Practitioner’s Name;
• Physician/Practitioner’s National Provider Identifier (NPI);
• Physician/Practitioner PTAN (optional); and
• Physician/Practitioner’s Address.
Home Health Agency Information
• Agency Name;
• Agency National Provider Identifier (NPI);
• CMS Certification Number;
• Agency PTAN (optional); and
• Agency Address.
Submitter Information
• Contact Name; and
• Telephone Number.
Other Information
• Benefit period requested (initial or subsequent);
• Submission Date;
• From and Through Date of the 60-day episode of care;
• Indicate if the request is an initial or resubmission review; and
• State where service is rendered.
Additional Required Documentation
Documentation from the medical record that supports the beneficiary is:
• Confined to the home at the time of services;
o Medicare considers the person homebound if:
1) There exist a normal inability to leave the home and
2) Leaving home requires a considerable and taxing effort. Additionally,
one of the following must also be true:
a) Because of illness or injury, the person needs the aid of
supportive devices such as crutches, canes, wheelchairs,
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•
•
•
•

and walkers; the use of special transportation; or the assistance
of another person in order to leave their place of residence; or
b) The person has a condition such that leaving his or her home is
medically contraindicated
Under the care of a physician;
Receiving services under a plan of care established and periodically reviewed by a
physician;
In need of skilled services;
Had a face-to-face encounter with a medical provider as mandated by the Affordable
Care Act. This encounter must:
o 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
o be related to the primary reason the patient requires home health services; and
was performed by an approved provider type.

Submitters should note that the start date for the home health episode covered by the pre-claim
review is the start date requested on the pre- claim review request. Submitters are encouraged to
use their respective MAC’s checklist specifically designed for pre- claim review requests. The
checklist assists submitters with ensuring requests are complete.
Submitters have four options for submitting pre-claim review requests to the MACs: 1) The
preferred and most expeditious method of submission: MAC Online Portal (where available), 2)
Electronic submission of medical documentation (esMD) (when available), 3) Fax, or4) Mail.
Please note the response will be sent to the submitters using the same method as the request was
sent if available.
Home Health Agencies should send requests to their appropriate MAC.
Palmetto:
• eServices
o www.onlineproviderservices.com
o *Palmetto GBA’s preferred method of submission
• esMD: (where available)
o For more information about esMD, see www.cms.gov/esMD or contact your
MAC.
• Fax Number: 803-419-3263
• Palmetto GBA – JM MAC Home Health Pre-Claim Review Mailing Address:
o PO Box 100234
o Columbia, SC, 29202-3234
NGS:
• eServices
o NGS Connex
• esMD: (where available)
o For more information about esMD, see www.cms.gov/esMD or contact your
MAC.
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•

Fax Number: MAC J6: 1-717-565-3840 or 315-442-4178
MAC JK: 1-315-442-4390

•

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

CGS:
• Online Portal: when available
• esMD: (where available)
For more information about esMD, see www.cms.gov/esMD or contact your MAC.
• Fax Number: 615-664-5950
• Mailing Address: CGS Administrators
PO Box 20203
Nashville, TN 37202

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Cases Where Services Are Not Covered Under the Medicare Benefit, Medicare is Primary,
and Another Insurance Company is Secondary:
Home Health providers or beneficiaries may submit the claim without a pre-claim review
decision if the claim is non-covered (GY modifier). A pre-claim review is not needed and the
claim will not be developed due to the pre-claim review demonstration. Services billed as not
medically necessary (GA modifier) will be developed and reviewed under the pre-claim review
demonstration.
If a home health provider or beneficiary chooses to use the pre-claim review for a denial then the
following process is to be followed:
• The submitter may submit the pre-claim review request with complete documentation as
appropriate. If all relevant Medicare coverage requirements are not met for the home
health benefit period, then a non-Affirmed pre-claim review decision will be sent to the
provider and to the beneficiary advising them that Medicare will not pay for the service.
• A claim with a non-affirmed decision submitted to the MAC for payment will be denied.
The claim must include the UTN provided in the decision letter.
• The submitter may forward the denied claim to his/her secondary insurance payee as
appropriate to determine payment for the home health benefit period.
Cases Where Another Insurance Company is Primary and Medicare is Secondary:
If a HHA plans to bill another insurance first and bill Medicare second, the submitter and
beneficiary have two options:
1. Seek Pre-Claim Review:
•

•
•

The submitter submits the pre-claim review request with complete documentation
as appropriate. If all relevant Medicare coverage requirements are met for the
home health benefit period, then a provisional affirmative pre-claim review
decision will be sent to the provider and to the beneficiary advising them that
Medicare will pay for the home health benefit period as long as all other r
requirements are met.
The provider renders the service and submits a claim to the other insurance
company.
If the other insurance company denies payment on the claim, the provider or
beneficiary can submit a claim in accordance with Medicare Secondary Payer
(MSP) provisions, to the MAC (listing the pre-claim review unique tracking
number (UTN) on the claim). The MAC will process the claim according to the
MSP provisions.

2. Skip Pre-Claim Review:
•
The provider renders the service and submits a claim to the primary payer for a
payment determination as appropriate.

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•

If the other insurance company denies payment on the claim, the provider or
beneficiary can submit a claim to the MAC in accordance with the MSP
provisions. The MAC will stop the claim for pre-payment review and will send an
Additional Documentation Request (ADR) letter. The provider should respond to
the ADR.

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Timeframe for Decisions:
• The MAC will make every effort to send notification of the decision to the submitter and
the beneficiary within 10 business days (excluding federal holidays) for an initial request.
•

A resubmitted request is a request submitted with additional documentation after the
initial pre-claim review request receives a non-affirmed decision. The MAC will make
every effort to send notification of the decision of these requests to the provider and the
beneficiary within 20 business days (excluding federal holidays).

Provider Telephone Inquiries:
Providers who have questions about the pre-claim review process should call the appropriate
MAC. The numbers for Customer Service Representatives at the MACs are as follows:
• For Palmetto GBA at 855-696-0705.
•

For NGS: MAC J6: 877-702-0990 TTY: 888-897-7523
MAC JK: 888-855-4356 TTY: 866-786-7155

•

For CGS: will be updated shortly

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Chapter 6: A Provisional Affirmative Decision
Provisional Affirmative Decision
A provisional affirmative decision is a preliminary finding that a future claim submitted to
Medicare for the service likely meets Medicare’s coverage, coding, and payment requirements.
Decision Letter(s):
The MAC will make every effort to send decision letters with the provisional affirmative preclaim review decision with a UTN number to the submitter via the MAC provider portal
postmarked within 10 business days for initial requests and 20 business days for resubmitted
requests. Decision letters sent via esMD are not available at this time. A copy of the decision
letter will also be mailed to the beneficiary.
Non-Transferability of a Provisional Affirmative Pre-Claim Request Decision:
• A provisional affirmative pre-claim review decision does not follow the beneficiary.
• Only one home health provider is allowed to request pre-claim review per beneficiary per
benefit period. In a situation where a patient is discharged and readmitted to the same
HHA during the 60 day episode, a new pre-claim review request is not needed unless a
separate claim will be filed.
o See CMS IOM 100-02, Chapter 7, Section 10 for further information on what
constitutes discharge for billing and payment purposes.
• A subsequent home health provider may submit a pre-claim review request to provide
home health services for the same beneficiary and must include the required
documentation in the submission.

Provider’s Actions:
• Render/deliver service/item.
• Submit pre-claim review request for an eligible service/item.
• Submit the claim with the unique tracking number (UTN) and the CMS Certification
Number (CCN) of the rendering provider on the claim.
o The submission of the pre-reviewed claim is to have the 14 byte UTN that is
located on the decision letter. For submission of a claim on a UB04 Claim Form,
the UTN is submitted in positions 19 through 30 in field locator 63. The last two
characters of the UTN should be written outside the lines next to position 30. For
submission of electronic claims, FISS shall accept the UTN following the
OASIS assessment data (Positions 1-18) in positions 19 through 32 of loop 2300
REF02 (REF01=G1) on type of bill 032x.
• If all requirements are met the claim will be paid.
• The pre-claim review demonstration has specific parameters for pre-payment review;
however other contractors (CERT, ZPICs, etc.) may have parameters outside of the PreClaim Review Demonstration that will suspend the same claim for another type of

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review. If your claim is selected for review, guidance and directions will be provided on
the Additional Documentation Request (ADR) Letter from the requesting contractor.

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Chapter 7: A Non-Affirmed Decision for Incomplete Requests
An Incomplete Request is Considered a Non-Affirmed.
When an Incomplete Request is Submitted:
• The MAC will make every effort to provide notification of what is missing with the preclaim review request to the submitter via fax, mail, or the MAC provider portal (when
available) through a detailed decision letter sent within 10 business days for initial
requests and 20 business days for resubmitted requests. A copy of the decision letter will
also be mailed to the beneficiary.
• The submitter may resubmit another complete package with all documentation required
as noted in the decision letter. See Chapter 8 for instructions on resubmitting a pre-claim
review request.
• If the claim is submitted to the MAC for payment with a non-affirmed pre-claim review
decision, it will be denied.
o All ordinary claim appeal rights will then apply.
o The claim could then be submitted to secondary insurance.
Providers Action:
• Resubmit a pre-claim review request, if appropriate.
• Use the home health pre-claim review request checklist/tool to ensure that the request
package complies with all requirements.

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Chapter 8: Resubmitting a Pre-Claim Review Request
•

The submitter should review the decision letter that was provided.

•

The submitter should make whatever modifications are needed to the pre-claim review
package and follow the submission procedures.

•

The MAC will make every effort to provide notification of the decision through a
decision letter sent within 20 business days of the review to the home health provider and
the beneficiary.

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Chapter 9: Claim Submission Where Pre-Claim Review was Sought
Cases Where a Pre-Claim Review Request was Submitted and Received a Provisional
Affirmative Decision:
• The submission of the home health claim is to have the UTN that is located on the
decision letter. For submission of a claim on a CMS-UB04 Claim Form, the UTN is
submitted in positions 19 through 30 in field locator 63. The last two characters of the
UTN should be written outside the lines next to position 30. For submission of
electronic claims, the UTN must be submitted following the OASIS assessment data
(Positions 1-18) in positions 19 through 32 of loop 2300 REF02 (REF01=G1) on type of
bill 032x.
• Final Claim:
o Should be submitted with the pre-claim review UTN on the claim.
o Should include the CCN of the rendering provider on the claim.
o Should be submitted to the applicable MAC for adjudication.
o If the provider changes during the home health benefit period, and the receiving
HHA did not submit a pre-claim review request, the claim will undergo a complex
medical review. The new home health provider is required to submit all medical
documentation to support the services billed.
Cases Where a Pre-Claim Review Request was Submitted and Received a Non-Affirmed
Decision:
• The submission of the home health claim pre-reviewed must include the UTN that is
located on the decision letter. For submission of a claim on a CMS-UB04 Claim Form,
the UTN is submitted in positions 19 through 30 in field locator 63. The last two
characters of the UTN should be written outside the lines next to position 30. For
submission of electronic claims, the UTN must be submitted following the OASIS
assessment data (Positions 1-18) in positions 19 through 32 of loop 2300 REF02
(REF01=G1) on type of bill 032x.
• Final Claim:
o Should be submitted with the pre-claim review UTN on the claim.
o Should include the CCN of the rendering provider on the claim.
o Should be submitted to the applicable MAC for adjudication.
• If the claim is submitted to the MAC for payment with a non-affirmed pre-claim review
decision, it will be denied.
o The standard claims appeals process will apply.
o This claim could then be submitted to secondary insurance.
See Appendix C - Claim Process When Pre-Claim Review Was Sought

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Chapter 10: Claim Submission Where Pre-Claim Review was NOT
Sought: The Prepayment Review Process
If an applicable claim is submitted without a pre-claim review request being submitted, it will be
stopped for pre-payment review. Home health final claims for benefit periods with a from date
prior to the start date in each state are not applicable for the Pre-Claim Review Demonstration.
At this time, providers do not need to do anything differently when submitting a claim without a
UTN. They do not need to put any information in the remarks field. They do not need to submit
any unsolicited documentation. They should include the CCN for the rendering provider on the
claim.
Stopping a Claim for Pre-Payment Review:
• The MAC will stop the claim and send an Additional Documentation Request (ADR)
through the US Postal Service or Online Provider Portal (if available).
• The HHA will have 45 days to respond to the ADR with all requested documentation.
• The HHA can send the documentation via:
o Online Portal (if available)
o Fax
o Mail
o esMD (if available, for more information see: www.cms.gov/esMD)
• The MAC will have 30 days to review the documentation and make a payment
determination.
See Appendix D. - Claim Process When Pre-Claim Review Was Not Sought

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Chapter 11: Claim Appeals
Appeals follow all current procedures. For further information consult the Centers for
Medicare & Medicaid Services’ Medicare Claims Processing Manual publication 100-04,
Chapter 29 Appeals of Claims Decision.
This Pre-Claim Review Demonstration does not include a separate appeal process for a nonaffirmed pre-claim review decision.
However, a non-affirmed pre-claim review decision does not prevent the provider from
submitting a final claim. Such a submission of a final claim with the UTN and resulting
denial by the MAC would constitute an initial determination on the claim that would make the
appeals process available for disputes by beneficiaries and HHAs.

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Appendix A: Example of Pre-Claim Review Request Process (Home Health Agency Submits)
Patient/beneficiary visits
Physician/Practitioner

Physician/Practitioner
documents in the
medical record the faceto-face (F2F) encounter
and medical necessity of
home health care
services and sends
documentation and
referral to the HHA

Notice of
Decision*

Physician reviews, signs
and dates POC and returns
to the HHA
HHA receives referral,
order and F2F encounter
documentation
HHA receives signed and
dated POC from certifying
physician
HHA develops Plan of Care
(POC) and submits to
attending/certifying
physician

If you disagree with the
decision, you can resubmit the
request
HHA submits the Pre-Claim Review
Package including:
•
Physician F2F encounter
documentation
•
Signed and dated POC/Certification
•
Documentation from medical record
to support medical necessity of home
health care services
•
Other supporting documentation

MAC receives package, reviews
package, makes pre-claim review
decision and sends notification
Initial submission: 10 days
Resubmissions: 20 days

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Notice of
Decision*

*If the decision is non-affirmed, the
notification will give the detailed
reason(s) why

Appendix B: Example of Pre-Claim Review Request Process (Beneficiary Submits)
Patient/beneficiary visits
Physician/Practitioner
Notice of
Decision*
Physician/Practitioner
documents in the
medical record the faceto-face (F2F) encounter
and medical necessity of
home health care
services and sends
documentation and
referral to the HHA

Physician reviews, signs
and dates POC and returns
to the HHA

HHA receives the signed
and dated POC from the
certifying physician
HHA receives referral,
order and F2F encounter
documentation
HHA provides the patient/
beneficiary with all
required documentation
HHA develops Plan of Care
(POC) and submits to
attending/certifying
physician
Patient/beneficiary submits the Pre-Claim
Review Package including:
•
Physician F2F encounter
documentation
•
Signed and dated POC/Certification
•
Documentation from medical record
to support medical necessity of home
health care services
•
Other supporting documentation

MAC receives package, reviews
package, makes pre-claim review
decision and sends notification
Initial submission: 10 days
Resubmissions: 20 days

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If you disagree with the
decision, you can resubmit the
request

Notice of
Decision*

*If the decision is non-affirmed, the
notification will give detailed
reason(s) why

Appendix C: Example of Claim Process (if Pre-Claim Review was sought)
HHA submits claim with
the Unique Tracking
Number (UTN)

HHH MAC receives claim
where pre-claim review
was provisionally affirmed

Pay Claim or
claim line

HHH MAC receives claim
where pre-claim review
was non- affirmed

Deny Claim
or claim line

Notice of Decision is
sent to provider
and
patient/beneficiary

If provider
disagrees with
decision, file
appeal
MAC receives appeal,
reviews and makes a
determination
If patient/
beneficiary
disagrees with
decision, file
appeal

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Appendix D: Claim Process (if Pre-Claim Review was not sought)

HHA submits final claim
HHA has 45 days to submit
documentation:
•
Physician signed and dated POC
•
Physician F2F encounter
documentation
•
Documentation from medical
record to support services billed
•
Other supporting documentation

HHH MAC receives claim
where pre-claim review
was not sought

HHH MAC stops claim for
pre-payment review and
sends HHA ADR letter

HHH MAC receives documentation,
reviews documentation, makes claim
payment decision within 30 days and
sends decision notice

HHA receives ADR letter

Is claim payable?
Yes, pay claim

No, deny claim

Notice of Decision is
sent to provider
and beneficiary

If HHA
disagrees with
decision, file
appeal
MAC receives appeal,
reviews and makes a
determination
If patient/
beneficiary
disagrees with
decision, file
appeal

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