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Printed Date: 9/22/2015
The Pre-Claim Review (PCR) Demonstration for Home Health Services began in Illinois on August 3, 2016. The demonstration was paused on April 1, 2017, as the Centers for Medicare & Medicaid Services (CMS) made revisions to the program to provide flexibility as a result of provider feedback. This article explains data Palmetto GBA collected during the PCR demonstration within the state of Illinois, to include Illinois affirmation rates, claim submission trends, and the top 15 non-affirmation reason descriptions.
The PCR demonstration permitted providers to submit one or more home health services as defined by HCPCS codes per request. Based on the request, providers could receive a decision of fully provisionally affirmed, partially affirmed, or non-affirmed. During the PCR demonstration, Home Health providers in the state of Illinois submitted 123,873 PCR requests, resulting in a combined fully provisional and partially affirmed rate of 97.5 percent at the conclusion of the demonstration. Excluding the partially affirmed PCR requests, the fully affirmed rate for the state of Illinois was 95.8 percent. A partially affirmed decision indicates at least one service was provisionally affirmed. The 57.5 percent increase of the combined fully and partially affirmed rate from 40 percent was a noticeable improvement from the beginning of PCR in April, 2016. Affirmation rate improvement can be attributed to extensive provider education, as well as assistance from PCR nurse reviewers calling home health agencies to review partially or non-affirmed requests. This allowed the agency to understand what was missing in the PCR submission and resubmit to receive a provisional affirmation.
During week 24 of the demonstration, ending on January 14, 2017, 88.5 percent of PCR requests received a fully affirmed decision. Overall in week 24, 91.7 percent of PCR requests received a fully affirmed or partially affirmed decision. The chart below identifies the affirmation percentage in the state of Illinois over the course of the demonstration. The blue line represents full provisional affirmation, the red line represents partial affirmations and the green represents a combination of full and partial affirmations.
During the PCR demonstration, Palmetto GBA identified a decrease in claim submissions. During the demonstration, Palmetto GBA received an average of 25,025 home health claims per month. After the demonstration was paused for review, Palmetto GBA identified an average increase in monthly claim submissions by greater than 5,000 versus the first three months of the year average.
Below are the top 15 non-affirmation denial reason descriptions from the PCR demonstration in the state of Illinois. The denial reason descriptions, which include the denial explanation and Internet Only Manual (IOM) reference, are listed in descending order.
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Last Updated: 03/11/2019