Preparing for Home Health Pre-claim Review

March 22, 2017

You’ve heard the warnings. You live in a state that’s getting ready to adopt CMS’ pre-claim review (PCR) program. But what do you do now? We here at therapyBOSS would like to share a few helpful tips from our home health clients who have gone through this process. Having observed their challenges, the first thing we would like to say is that CMS’ PCR program is not the “gotcha” some make it out to be. With preparation and diligence in execution, there is no reason that your pre-claim approval rate should not be 99.9% (and really 100%). So, it is with preparation in mind that we are publishing this first article of a few more to come. We will walk you through some proven methods for getting ready, submitting the pre-claim review, and appealing a non-affirmed decision. Let’s begin with the initial groundwork.


Establish the person or group who will be responsible for coordinating the PCR process in your agency. It will be helpful if this group at least includes the employee who performs your clinical chart review and the individual doing billing.


Make sure you are signed up for email updates from your fiscal intermediary. As of the date of this article, Illinois is the only active state doing PCR and Florida is scheduled to go active April 1, 2017. Both states have Palmetto GBA as their fiscal intermediary. All related Home Health Pre-Claim Review information is conveniently featured on Palmetto’s website. You can visit the Event Registration Portal to schedule to attend a PCR webcast, read through the FAQs, review job aids and workshop handouts, and print out an actual submittal request form to see what information will be required.


If your documentation is still on paper, and even with an EMR in place, you are likely to need to scan some paperwork to ready it for submission. If you decide to invest in a quality scanner capable of handling multiple pages and double-sided scanning, consider the inexpensive Canon imageFormula DR-C225. In case you are planning to submit via fax or regular mail, which is significantly less efficient and we do not recommend it, you will naturally need a reliable printer, copier, and fax machine.


For the following steps, we will go into further detail in our subsequent articles on the subject to be published soon. They are summarized here to get you thinking about the personnel assignments you will need to evaluate. Know who will be responsible for each step.

  1. The process begins at the time of the referral with intake personnel making sure that the face-to-face progress note (this is the physician patient encounter note) is complete.
  2. Your clinical reviewers will need to ensure that documentation is compliant before it is released to billing and pre-claim.
  3. Assign the individual, or individuals depending on the volume, to oversee compiling the required documentation for submission. This person will ready “the packet” to be submitted. Billing, medical records or intake staff can perform this task provided they are detail-oriented and organized.
  4. Designate who will be submitting compiled information on behalf of your agency and what method will be used for submission. It is easiest to have this person be the same employee who prepares the documentation for submission.
  5. Choose the staff member to assume responsibility for tracking PCR responses from the intermediary. Unless your patient census is close to or above one hundred, the person preparing documentation and submitting it can be assigned to this step.
  6. Appoint the personnel to manage and respond to non-affirmed PCR statuses. This optimally will be a team effort between the individual preparing/submitting/tracking and a clinician from your documentation review/compliance team.


As many of our clients in Illinois have discovered, you may find it very helpful to create a pre-claim review/documentation form which clinical staff can begin completing at the time of the RAP billing audit by identifying the services that will be performed and answering the clinical questions asked in the PCR process. We have developed just such a form. Feel free to use it as is or revise it, if needed, to fit your own effort. This tool can easily organize and guide even a non-clinical member of your team.


Establish a spreadsheet type of 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 PCR while you wait for signed orders or other documentation to come to the office. We have created a tracking form that you can use. This will keep all missing information organized so that the responsible individual can quickly follow up to see if documentation has been received.


If you plan on submitting your requests electronically, which you should, make certain that the personnel responsible for submissions are set up with their own logins in the PCR system. For Palmetto GBA, it is their eServices portal.


Ensure you receive a provisional affirmed status on all HCPCS (billing visit codes) sent and that you record the Unique Tracking Number (UTN) received using the spreadsheet-based tracking system in section VI. You will receive PCR response letters the same manner as your submission. If you use eServices, check the portal a few times per week for new PCR decisions. Ensure that there is a way to identify and exclude LUPA episodes from the process.


Create a procedure for timely resubmission of all non-affirmed PCRs. You will be notified of these through the same portal that PCRs are submitted from and, as of the date of this article, Palmetto reviewers are making educational calls to alert providers of non-affirmed PCRs and advise them in how to correct them. Therefore, verify the phone number on your submission is correct. Often, additional evidence will be required to answer the deficiencies cited in the PCR decision letter. Remember that you cannot bill the final claim without an affirmed Unique Tracking Number (UTN). If you cannot obtain it promptly, you will be risking your RAP auto-cancelling. And excessively high RAP cancellation rates (total RAPS cancelled/total final claims processed in a month greater than 25%) will put your agency at risk for zero payment on all your RAPs, forcing you to submit a Corrective Action Plan and accept increased monitoring by the fiscal intermediary.


Test your process prior to the planned start date. Designate a few days in your test cycle and make sure all patients are captured and all documents are complete. Identify any gaps before your go-live date to ensure a smooth implementation.

If your agency runs therapyBOSS with their contracted therapy staffing providers, let our software help you make your process easier. Quickly extract documentation as PDF any time you need it. Create QI activity notes to flag records that are not ready for submission and make a note of what information is missing. Communicate effortlessly with clinicians using the built-in messaging to facilitate corrections. Please contact usfor more information.