Joe Osentoski, BAS, RN-BC
ADR and Appeals Specialist
Gateway Home Health Coding & Consulting LLC
Medicare Administrative Contractor Jurisdiction M Palmetto GBA sent out a reminder that agencies selecting Choice 1 (Pre-Claim Review) can start to submit their claims as of March 2, 2020. Texas PCR
An overwhelming number of Texas agencies (89%) who made their RCD selection went with the pre-claim choice Texas RCD Choices. So for these agencies, Palmetto GBA reminds you that for any billing period on or after March 2, 2020, you will need to submit these for review and obtain a Unique Tracking Number (UTN). The UTN will be needed for the final claim submission to avoid an automatic Additional Development Request (ADR) and 25% payment reduction. Thus for a claim under Patient Driven Groupings Model (PDGM) 30-day billing periods, this could include the second 30-day period of a 60-day episode, if that second 30-day period started on or after March 2, 2020.
Palmetto GBA has posted multiple job aids to assist agencies in navigating Pre-Claim Review PGBA PCR. Reviewing these is recommended to get your Pre-Claim reviews off to a good start. And don’t forget that CMS has posted FAQs for RCD, updated as of January 6, 2020, so you can learn from others’ questions on the entire RCD process RCD FAQ.
Keep in mind that Palmetto GBA has also posted multiple helpful articles to assist with accurate claim submission on their website PGBA RCD Articles. Agencies should make it a habit of attending the monthly PGBA teleconference on RCD that allows for questions on specific agency issues PGBA Monthly RCD Call as well as a quarterly call on the topic PGBA Quarterly RCD.
Doing this will ensure that key information is not missed when PGBA makes significant changes within RCD, such as phasing in the requirement that Low Utilization Payment Adjustments (LUPAs) are subject to pre-claim submissions and ADRs RCD LUPA.
For the Texas agencies under RCD Choice 2 (100% Postpayment Review), stand by to start receiving ADRs on every final claim submitted on or after March 2, 2020. Since Choice 2 is the default option in case no selection was made for RCD, the sudden appearance of ADRs on every final claim will require a clear process put in place to handle this for the next six months and maintain cash flow while claims are in the ADR process.
So Review Choice Demonstration is here. Resources are available to successfully negotiate it. It’s go time!