Things you should know about CMS Pre Claim Review

The Medicare Claims Management System (CMS) oversees a number of federal health insurance programs, including the Pre-Claim Review Demonstration (PCRD). The PCRD is a new initiative that is designed to reduce Medicare fraud and abuse. Under the program, Medicare will review certain claims before they are paid.

The PCRD is currently being piloted in four states: Florida, Illinois, Texas, and New York. The program is expected to be expanded to all fifty states in the coming years.

The CMS pre claim review Demonstration has the potential to save the government billions of dollars each year. However, the program also has the potential to disrupt the practices of healthcare providers who are not prepared for it.

At first glance, the PCRD may seem like another burden for home health agencies. However, there are several ways in which the demonstration can actually improve your practice. Read on to learn more about how the CMS pre claim review Demonstration can affect your home health practice!

What does CMS pre claim review mean?

What does CMS pre claim review mean?

According to CMS announcement;

“Through this demonstration, CMS aims to test the level of resources required for the prevention of fraud instead of engaging in ‘pay and chase’ and to determine the feasibility of performing pre-claim review to prevent payment for services that have high incidences of fraud,” according to the CMS announcement.

The Partnership for Quality Home Healthcare remains steadfastly opposed to the project. In a statement, the coalition of acknowledged the transition to a pre-claim review alleviates concerns about limiting access to home health services but argued the project “creates new challenges for home health agencies in providing seamless, integrative high quality skilled health care.

Pre claim is a term used to describe the notification of an insurance claim prior to the actual occurrence of the event. This can be done either by the policyholder or the insurance company. By notifying the company early, the policyholder can help to ensure that the claim is processed more quickly and efficiently. Pre-claim can also be used as a way to get an estimate of the potential damages.

The Centers for Medicare & Medicaid Services (CMS) requires that MA and/or Part D sponsors verify the applicant’s eligibility for the Medicare program prior to enrolling the applicant into the plan. This is to ensure that only those individuals who are eligible for Medicare enroll in the plan.

During the pre-claim status, insurance sponsor will verify the applicant’s Medicare eligibility. Once the eligibility is verified, the enrollee will be moved to active status and will be able to receive benefits under the plan.


What is the pre-claim review demonstration?

What is the pre-claim review demonstration?

The Pre-Claim Review Demonstration is a pilot program that is being tested in select states. Under this program, Medicare will review your medical records before you receive services to see if the care being recommended is necessary. This is called a “pre-claim review.”

If you live in a state where the Pre-Claim Review Demonstration is being tested, you will be notified by Medicare if you are selected to participate. You can also call 1-800-MEDICARE (1-800-633-4227) to find out if you are eligible to participate.

If you are selected to participate in the Pre-Claim Review Demonstration, you will be asked to provide Medicare with information about the care you are requesting. This may include your medical records, a summary of your medical condition, and information about the care you are enrolled of.

The goal is to ensure that home health services are medically necessary and meet all Medicare requirements before payment is made.

This program is currently being piloted in select states, including;

  • Illinois – August 1, 2016 – Paused 
  • Texas – December 1, 2016 – Delayed
  • Florida – October 1, 2016 – April 1, 2017 – Delayed
  • Michigan – January 1, 2017 – Delayed
  • Massachusetts – January 1, 2017 – Delayed

Who does pre claim review affect?

Who does pre claim review affect?

Pre-claim review (PCR) is a process in which states review certain claims for payment before they are processed by the health plan. PCR affects claims for certain services that are provided by certain types of providers.

PCR requires Medicare beneficiaries to submit medical documentation to CMS before they can receive coverage for certain services. CMS will then review the documentation and determine whether the beneficiaries are eligible for coverage. If they are not, CMS will not reimburse the provider for the services rendered.

This program will affect all Medicare beneficiaries who receive services that are subject to PCR. In Illinois, Florida, and Texas, that includes home health services, hospice services, and Skilled Nursing Facility (SNF) services. Beneficiaries who receive these services in other states are not currently subject to PCR.

PCR is conducted on a case-by-case basis. A claim will be reviewed if it meets all of the following criteria:

– The service is provided by a provider type that is subject to PCR.

– The service is not an emergency service.

– The service is not a preventive service.

– The service is not a service that is rendered by a provider who is employed by or under contract with the state.

If it is determined that a claim should not be paid, the provider will be notified and given the opportunity to appeal the decision.

What to do to prepare for pre claim review demonstration?

What to do to prepare for pre claim review demonstration?

Pre claim review demonstration (PCRD) is a new Medicare initiative that seeks to improve care coordination and reduce costs for beneficiaries with electronically-connected health care providers. Under PCRD, Medicare will review certain claims before they are processed to ensure that beneficiaries are receiving the care they need and that services are being provided in the most efficient way possible.

As a provider, you can prepare for PCRD by signing up for electronic claims submission, connecting with other electronically-connected providers, and ensuring that your billing staff is familiar with the PCRD process. You can also review the PCRD fact sheet and frequently asked questions for more information. Other than that, you can do a few things to prepare for pre-claim review demonstration. First, you should clearly understand the program and its requirements. You should also have all of the necessary documentation and paperwork in order. A list of documentation that is required can be found on the CMS official website. Lastly, it is always a good idea to be familiar with the claims process and to have a claims representative on hand to help with any questions or concerns you may have.