Inpatient Rehabilitation Facility Review Choice Demonstration Additional Documentation Request Process

The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services provides flexibility and choice for IRFs, as well as a risk-based approach to reduce burden on providers demonstrating compliance with Medicare IRF rules. IRFs will initially select between two review choices:

• Choice 1: Pre-Claim Review — The provider submits the pre-claim review request and receives the decision prior to claim submission; however, the provider will begin services before submitting the request. A Unique Tracking Number (UTN) must be submitted on the claim, or it will result in a pre-payment additional documentation request (ADR). During pre-payment, most billing errors will trigger an automated ADR. 
• Choice 2: Postpayment Review — The provider submits the claim for each admission. The claim will be processed and paid per CMS guidelines; however, the Medicare Administrative Contractor (MAC) will send an ADR and follow CMS postpayment review procedures. This is an automated process for finalized claims. 

After a six-month period, IRFs demonstrating compliance with Medicare rules through their end-of-cycle rate calculations will have additional review choices to select from. IRFs may select from one of the three subsequent review choices:

• Choice 1: Continue with Pre-Claim Review
• Choice 3: Selective Postpayment Review — The MAC selects a statistically valid random sample every six months, based on the previous six months’ claim volume. The MAC sends ADRs and follows CMS’ postpayment review procedures
• Choice 4: Spot Check Pre-Payment Review — The MAC selects 5 percent of IRF claims every six months, based upon the previous six months of claim volume. The MAC sends ADRs and follows CMS’ pre-payment review procedures

This program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay care to Medicare beneficiaries. This RCD protects our programs' sustainability for future generations by serving as a responsible steward of public funds.

The ADR Submission Process

Timing is a critical step in the successful submission of an ADR. The checklist will assist you through this process. The IRF will have 45 days to respond to the ADR. The following consequences will occur for untimely submissions: 

• Denied claims for non-response on day 46 
• An overpayment will be initiated for postpayment claims only. Pre-payment claims will be denied, and no payment will generate. 

Pre-Claim Review: If an applicable claim is submitted without a pre-claim review request submitted, and the provider has selected Choice 1 – Pre-Claim Review, it will be stopped for pre-payment review.

Pre-Payment Review: Service specific pre-pay medical review of claims requires that a medical review determination be made, prior to claim payment directed at a certain service. It includes requests for, collection and evaluation of medical records or any other documentation   . Reviewers shall consider documentation in accordance with Medicare coverage rules and conditions.

Postpayment Review: Reviewers shall consider documentation in accordance with Medicare coverage rules and conditions. The postpayment review under this choice will follow the same review standards as are in place absent the demonstration. 

Appeals: The IRF retains all appeal rights for denied claims. The RCD does not include a separate appeal process for a non-affirmed pre-claim review decision. 

However, a non-affirmed pre-claim review decision does not prevent the IRF from submitting a final claim. A submission of a final claim with a non-affirmed UTN and resulting denial by the MAC would constitute an initial determination on the claim that would make the appeals process available for beneficiaries and IRFs.

Appeals will follow all current procedures no matter which choice an IRF selects. For further information consult the Chapter 29 of the CMS Internet-Only Manual Pub. 100-04, Appeals of Claims Decisions.

References

• IRF RCD Operational Guide (PDF)
• Medicare Benefit Policy Manual (PDF)
• Medicare Program Integrity Manual (PDF)
• IRF_RCD_ADR_Checklist (PDF)