Home Health Pre-claim Review Submission

March 29, 2017

If you haven’t yet, read our article on preparing for home health Pre-claim Review (PCR) for helpful tips and tools to get started. Stay tuned for more content, including how to appeal a non-affirmed pre-claim decision. In this post, I will take you through the pre-claim submission process with special focus on Palmetto GBA’s eServices web portal as this is the recommended method for submitting.


The process begins at the time of the referral with your intake making sure that the face-to-face progress note (this is the physician patient encounter note) is:

  • an actual legitimate progress note which meets CMS standards of a progress note and clarified further in Palmetto GBA’s education on the criteria for the clinical note,
  • dated within 90 days prior to or 30 days after the start of care date,
  • related to the reason your agency is providing home health services,
  • co-signed by a supervising MD if the note is done by a Non-Physician Practitioner such as a Physician Assistant, Certified Nurse Midwife or Nurse Practitioner, and
  • co-signed by the certifying physician that he or she incorporated it into their medical record if someone other than the certifying physician performed the initial face-to-face encounter.


Your intake should also be responsible for collecting the MD orders for home health, facility discharge paperwork (if the patient came from a facility), and any visit notes from the facility that help establish the patient’s homebound status and medical necessity.


Have your clinicians educate clients at the time of admission about the pre-claim review process. They will be receiving copies of all pre-claim review decisions pertaining to their care. Non-affirmed pre-claim review decisions could be confused with denials for patients who are not prepared. Stress to your patients that they can contact your agency with any questions about CMS correspondence pertaining the home health treatment they are getting.


Once the admission or recertification paperwork is submitted, clinical reviewers in the office need to verify that the documentation is complete. Their task is to ensure that medical necessity and homebound status are thoroughly documented and all evaluations and progress notes can stand on their own to reflect the skilled services provided. Consider utilizing the pre-claim review form that we offered in our previous article. It should be filled out at the time of the RAP billing audit. Here are some helpful tips about this form (or even if you are not using it):

  1. Patient demographics can be taken from the plan of care/485 form.
  2. Remember when choosing your HCPCS codes to ensure that you are thinking about all services the patient may need – choose RN and LPN codes if nursing is involved so that you have allowed for your LPN to cover the patient if the RN becomes unavailable. Choose PTA and OTA codes along with PT and OT if you use contract therapy companies since you may not have control over which contracted staff members see your patients. Include Observation and Assessment and Teaching and Training codes even if your case initially starts out as only Hands On Care (for example, once a wound has healed, your nurse may continue to see the patient to monitor the wound site and teach about nutrition and skin care).
  3. Make sure that Management & Evaluation and Maintenance visit codes are supported by the documentation in the plan of care and face-to-face progress note.
  4. For the facility discharge question, determine the most recent facility that the patient was discharged from if he or she has been in more than one. Palmetto’s online submission system only allows for one selection.
  5. Choose whether the person who completed the face-to-face encounter and the physician who is certifying the home health care are the same person. If they are not, select the provider type from the list given. Remember that if the certifying physician did not perform the face-to-face encounter, he or she must co-sign the face-to-face progress note to show that they have reviewed it and incorporated it into their medical record. If it is not co-signed, your submission will be returned as non-affirmed.
  6. Mark whether the beneficiary needs any assistance to leave the residence (supportive device such as a wheelchair or crutches or special transportation or assistance of another person). You do not need to specify what kind of assistance is needed in the question. The documentation that you attach to Task 5 must provide the evidence of the support the client requires. If you are using our recommended form, ensure that the OASIS, therapy evaluations/care plans and MD encounter face-to-face progress notes clearly spell out the assistance required. If the patient does not require assistance to leave the residence, then they must have a condition that makes leaving home medically contraindicated. If neither situation applies, the patient fails the first homebound test and does not qualify for Medicare services.
  7. Select whether there is a normal inability to leave the home. Make sure that the documentation you attach to Task 6 contains the details to support your response to this question. Note, if the patient does not have a normal inability to leave home, the patient fails to meet Medicare’s homebound requirement and does not qualify for Medicare services.
  8. Select whether leaving home requires a considerable and taxing effort. Task 7 documentation will substantiate this response. Keep in mind that answering no to this question will disqualify the patient from meeting the Medicare homebound requirement. After answering yes to the considerable and taxing effort question, choose at least one Structural Impairment, Functional Impairment and/or Activity Limitation that applies to the patient. Choose as many as are appropriate keeping in mind that the documentation in Task 7 must support these responses as well.
  9. Forward the completed pre-claim review form to your submission personnel.


The next step in the process is to have your designated pre-claim review submission person prepare the documentation. Billing, medical records, or intake staff are all great candidates to ready “the packet” to be submitted. This individual is responsible for ensuring that all identified documents are scanned as needed and ready to go. Create a folder on your network called “Preclaim” accessible only to those staff members who submit pre-claim reviews and clinical staff who will assist in the pre-claim appeals process. Within the “Preclaim” folder, each patient will have their own named folder with a sub-folder for each episode. Establish a naming convention such as 20170401-Smith-task1a.pdf where the date is the start of the episode, the name is the last name of the client, and the task number is included so that there is no error in submission. Remember that each uploaded file must have a unique name. If you attempt to send two files with the same name, even if attached in different tasks, your submission will fail. Some of our more successful Illinois clients have made it a practice to include a brief cover letter on the face-to-face documentation, pointing out key aspects such as encounter date, physician signature, and certifying physician co-signature to ensure reviewers do not miss them. Remember to include a physician signature log if the signature on any paperwork is not legible.


As noted in our previous article, establish a spreadsheet tracking system for documents that need to be followed up on. For example, you will not have the plan of care signed by the physician immediately when billing has been finalized. You may need to hold the submission of the pre-claim review while you wait for signed orders or other documentation to come in to the office. We have developed a tracking sheet for you to use or customize to your needs. Follow up on missing documents a few times a week to confirm whether paperwork has been received.


Once all documents have been received and scanned (or saved from your electronic documentation system), the designated staff member in your office will submit the information to the fiscal intermediary. If your fiscal intermediary is Palmetto GBA, the preferred method of submission is their eServices portal. It is the most optimal approach as it ensures your submitter answers all of the questions asked and attaches all documentation to the proper task. You will get a confirmation of the submission right away and the response will come via the same eServices portal which makes tracking very easy. To submit using eServices, sign into the portal and click on the Pre-Claim Review link at the top of the page. Then click on the Pre-Claim Review Form link to open the submission screen and follow the prompts. If you would like more instruction on how to submit the pre-claim review in the Palmetto eServices system, this video from Palmetto GBA will walk you through the process. Skip to about 10 minutes and 30 seconds into the video for step-by-step instructions. Palmetto also allows submission via esMD, fax, and hard copy mail but we do not recommend these methods as it will be slower to produce a response and more prone to errors. Whichever method of submission you choose, your response will be received the same way.


Use your tracking system to ensure you receive a provisional affirmed status on all HCPCS (billing visit codes) sent and that you record the Unique Tracking Number (UTN) received. If using eServices, initial pre-claim review requests will get a response within 10 business days and resubmitted pre-claim review requests take about 20 business days according to the most recent FAQs from CMS. Keep in mind that you do not need to submit an additional pre-claim review if you add new services in the middle of the episode and you do not need to submit a pre-claim review at all if your claim is going to be a LUPA (a claim of 4 visits or less).


Speaking of LUPAs – be very careful with those claims. Monitor episodes that are planned as LUPAs to ensure that more services are not added in the middle of the episode to take them out of LUPA status. As soon as you know that the episode will not be a LUPA, you must submit a pre-claim review. But make certain that the paperwork you submit for the review includes the evidence of the change in the patient’s condition. At a minimum, incorporate frequency change orders to show that the number of visits has exceeded the LUPA threshold and the Other Follow-Up OASIS if completed. If you submit the pre-claim review with just the original documentation, the reviewer will deny it as not appropriate because the plan will show four visits or less. Any final claim that is a LUPA must have the UTN deleted before the claim is transmitted.


All non-affirmed pre-claim reviews should be resubmitted as soon as possible with any additional evidence required to answer deficiencies cited in the pre-claim decision letter. Remember that you cannot file the final claim without an affirmed UTN. CMS has already cautioned agencies that RAPs will continue to auto-cancel if the final claim is not filed by the greater of 120 days after the start of the episode or 60 days after the paid date of the RAP. Agencies with a 25% or higher RAP auto-cancel to final claim ratio in any given month are at risk for Zero Payment on RAPs, a requirement to submit a Corrective Action Plan (CAP) to correct process deficiencies and monitoring by the fiscal intermediary to ensure improvement.


Finally, your billing personnel must ensure that the UTN for the pre-claim is correctly noted in your billing software before submitting the final claim. Check with your billing software company to see if you need to install any updates to your software to accommodate the UTN number. Look at the billing file before you send it to verify that the UTN number is listed after the OASIS claim key for any final claims being submitted. Don’t forget, if you have a LUPA claim, omit the UTN number. Your claim with go into t-status (RTP-return to provider) if you attempt to submit a LUPA claim with a UTN number even if your original plan of care was for more visits.

We realize that starting something new can be daunting but our client agencies in Illinois report that Palmetto has done a lot to improve the pre-claim review submission process. There are lots of resources to review on their website and their reviewers have been following up non-affirmed pre-claim decisions with phone calls to the providers to further their education. With some planning and organization, you will be successful.