Pre-claim review delayed--except in Illinios

I'm so glad pre-claim reviews won't expand yet. I truly feel for Illinois in all of this mess!

From CMS:

Pre-Claim Review Demonstration for Home Health Services


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

The CMS 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.  This education effort 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submitted requests for episodes of care that began prior to August 3, 2016 and allow them to either have the requests withdrawn or processed as test requests.  


The Centers for Medicare & Medicaid Services (CMS) is implementing a three-year Medicare 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 also testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.   

The pre-claim review demonstration 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 beging 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 prepayment 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

For additional information please refer to the download sections below.

Questions about this demonstration may be sent to

Read it all on CMS' website as well.

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