CMS: Pre-Claim Applies to ‘Neighboring States’ Where Beneficiaries Live

If an Illinois home health agency is providing services to beneficiaries in a neighboring state, the claims for those patients must also go through the pre-claim review process, CMS has clarified in an update to an online FAQ doc.

“[An agency is] included in the demonstration for services provided to beneficiaries in the demonstration state as well as services provided in the neighboring non-demonstration state,” the updated document states.

The new guidance addresses a question as to whether PCR is activated by agency location or beneficiary location, Illinois HomeCare & Hospice Council Executive Director Sara Ratcliffe said.


“This FAQ seems to clear that up and is consistent with the other points listed [in the FAQ doc],” Ratcliffe told Home Health Care News. “So yes, it looks like if the agency is in Illinois and the beneficiary is in Wisconsin, say, they will need to go through PCR.”

The pre-claim demo currently is underway only in Illinois, with the program rollout temporarily on hold in four other states.

Under PCR, home health providers must submit documentation to a Medicare Administrative Contractor (MAC) auditor prior to filing the claim for payment.


If the documentation is in order, the auditor “affirms” the claim, enabling the agency to submit it for payment. If problems are identified, the MAC auditor issues a non-affirmation, and the agency must address the issues and re-submit the claim for pre-review.

So far, PCR is underway only in Illinois, where non-affirmation rates initially were very high. But the affirmation rate has been trending positively, according to CMS.

Practice Helps

Home health agencies become more successful in the Pre-Claim Review (PCR) demonstration with practice, CMS states in documents recently posted online. One sign of this: Home health agencies with the most PCR submissions tend to have the highest overall affirmation rates.

“There is a strong correlation between the number of submissions sent by a HHA and the number of provisionally affirmed decisions received,” the federal agency stated, citing newly released PCR data gathered through the end of October.


Specifically, home health agencies that have received at least 10 PCR decisions averaged a provisional affirmation rate of 81%. This is compared with an average provisional affirmation rate of 62% for agencies that received fewer than 10 PCR decisions.

Overall, the average provisional affirmation rate—which includes both full and partial affirmations—also has been increasing in Illinois. This is due to HHAs becoming more experienced in the process, auditors doing proactive outreach to those receiving non-affirmations, and additional education, according to CMS.

Until Nov. 1, agencies were in a grace period, in which they were not required to submit all their claims for PCR review. Agencies warned that auditors might be swamped by a higher volume of pre-claim submissions following the grace period. CMS still has not released data from November.

Written by Tim Mullaney

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