Pre-Claim Review Non-Affirmations

August 30, 2019

You are already familiar with the Home Health Review Choice Demonstration and Home Health Pre-claim Review Submissions. Recently, PalmettoGBA (PGBA) released some important information regarding Pre-Claim Review (PCR) Non-Affirmations that pertains to home health agencies in Illinois and will soon apply to Ohio agencies as well. This is valuable insight into what PGBA is looking for when reviewing PCR submissions.

What is a Non-Affirmation?

A Non-Affirmation is when an agency submits a PCR for an episode but at least one service that they have submitted for is not approved.

What Can We Do?

The good news is that a Non-Affirmation can be appealed. An agency may submit additional supporting documentation or resubmit with a letter pointing out which documents and sections should be re-reviewed for evidence to support the patient’s clinical need, homebound status, or other information that was identified as deficient. PGBA is following up with educational phone calls to ensure that agencies understand what was incomplete and suggesting documentation which may help to obtain an Affirmed status for the service in question. Make sure you reference the original Non-Affirmation number when submitting your appeal.

The problem is that appeals take time. It can take around two weeks to get a response on an appealed PCR submission. Adding the time it takes to process paperwork, identify and gather the required documents, the time for the original PCR and potentially more than one appeal, it is possible that your final claim could be held up waiting for an Affirmation which could cause your RAP to auto-cancel.

How Do We Avoid Non-Affirmations and Delays?

Your best course of action is to understand what PGBA is looking for and ensure that you can find that information in the documentation you submit. Review the Pre-Claim Review Initial Checklist and Pre-Claim Review Subsequent Episode Checklist for recommended documents for the first episode (generally the start of care episode) and subsequent episodes (generally recertifications). These documents map each task to typical home health documents that tend to contain the evidence required under the task.

All Medicare home health patients are required to be homebound so ensure your homebound documentation is complete by checking the Pre-Claim Review Non-Affirmations: Homebound article. Remember that every note should address the patient’s homebound status which includes documenting the clinical condition, illness or injury that restricts the patient’s ability to leave home without assistance, the patient’s normal inability to leave home and that leaving home requires a considerable and taxing effort. All therapyBOSS notes give clinicians the tools to thoroughly document homebound status. The article also points out the level of detail the MAC is looking for and gives examples of other areas of clinical notes that could potentially contradict homebound status such as no problems with balance or coordination, no assistive devices, and independent ambulation and transportation.

If your PCR includes a Face-to-Face Encounter, review this PGBA Pre-Claim Review Non-Affirmations: Face-to-Face Encounter article to see the main reasons for Non-Affirmation decisions for them. Ensure your face-to-face is included in your submission, the physician documented the date of the encounter and it was either within 90 days before or 30 days after the start of care date, and that the encounter was related to the reason you are providing home health services. It is important to review the face-to-face encounter as soon as it is received to ensure that it contains all required elements. If anything is not included, you can contact the physician to request an addendum to the note (if it was omitted in error), or you may have to arrange for your patient to see their physician again so that the physician can document an encounter related to the home health episode.

Review the PGBA Pre-Claim Review Non-Affirmations: Therapy article to ensure that your therapy orders and clinical documentation are meeting clinical guidelines. Evaluations must include measurable treatment goals related to the patient’s diagnoses, must be reasonable and necessary and must be of a complexity that requires the skills of a qualified therapist. Evaluations must include the reason for treatment, diagnoses, prior level of function, cognitive function, current level of function, objective measurements, interventions related to the illness or injury, patient limitations which may impact treatment time, short and/or long-term goals in objective measurable terms with their expected end date, and frequency and duration of services.

The Wrap-Up

Please don’t think that you can escape these criteria by choosing another Review Choice Demonstration method. These same criteria being reviewed for Pre-Claim Review will also be looked at under Postpayment Review and Minimal Review Recovery Audit Contractor (RAC) audits. The good news is that therapyBOSS helps facilitate the documentation of homebound status and all cited therapy items within our evaluation and visit notes. Clinical managers can use the QA featureto review, approve (with status=done), or track documents that are incomplete or inconsistent (with status=paused or failed). To submit questions about this article, connect with us on Facebook.