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Printed Date: 9/22/2015
In response to the Public Health Emergency (PHE) for the COVID-19 pandemic, claims submitted on or after March 29, 2020, are not required to go through the RCD process. Palmetto GBA will process claims submitted prior to the emergency period under normal claims processing requirements.
Choice 1 – Pre-Claim Review (PCR)
If you are in Choice #1 and decide not to submit any Pre-Claim Review (PCR) requests during this time, you will not be subject to the 25 percent reduction and you will not receive any pre-payment Additional Documentation Requests (ADRs). Following the end of the PHE, Palmetto GBA will conduct postpayment review on claims subject to the demonstration that were billed and paid during the pause.
You may continue submitting your PCR requests as normal and you will continue to receive decision letters and Unique Tracking Numbers (UTNs) to attach to your claim. These claims will continue to be excluded from further review.
If you have already submitted a PCR request and received a non-affirmative decision, you may continue the standard PCR process and resubmit to obtain an affirmative decision. Once you receive your affirmation, you will submit your claim with the affirmed UTN.
If you submit a claim with a non-affirmed decision and leave off the UTN, your claim will return-to-provider (RTP) requesting you to add the UTN. If you submit your claim with a non-affirmed UTN, the claim will deny based on the PCR decision. If you submit a claim with a non-affirmed UTN and the claim denies, you cannot go back and request a resubmission because you have already billed the claim. The standard appeals process will apply; for appeals process information click here.
You can also choose to submit PCR for some claims and skip PCR for other claims. However, please note that any claims that are normally subject to PCR will be reviewed on a postpay basis after the PHE has ended.
If you selected PCR you can:
Choice 2, 4, or 5 (ADR Reviews)
If you are on an ADR option:
Reference: the CMS website.
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Last Updated: 04/13/2020