The Centers for Medicare and Medicaid Services (CMS) recently announced it will implement a pre-claim review demonstration for home health services. The three-year demonstration will apply to home health services performed in Illinois, Florida, Texas, Michigan, and Massachusetts. It will begin as follows: in Illinois after August 1, 2016; in Florida after October 1, 2016; in Texas after December 1, 2016; and in Michigan and Massachusetts after January 1, 2017.

Under the demonstration, home health agencies (HHAs), the entity billing on the HHA’s behalf, or the beneficiary (collectively, a submitter) will have the option, but not the obligation, to submit a request for pre-claim review to the appropriate Medicare administrative contractor (MAC) prior to providing services to beneficiaries. Once a request is submitted, the MAC will review the request and all supporting documentation to determine whether the HHA satisfies the Medicare coverage and documentation requirements for the applicable service. Each MAC is required to make “all reasonable efforts” to issue a decision on the pre-claim review within 10 business days. HHAs will provide the services while waiting for a decision on the pre-claim review from the MAC. If the MAC disapproves, the submitter may revise the review request, including supporting documentation, and resubmit it an unlimited number of times. The HHA and beneficiary will be notified of the decision on subsequent submissions within 20 business days. In the notice, CMS directs the HHAs to provide the necessary care while awaiting a determination from the MAC.