CMS Makes Changes to Review Choice Demonstration

POSTED ON MONDAY, August 24, 2020

Last week, CMS announced a phase-in approach for RCD for North Carolina and Florida. Due to the public health emergency, both states were to begin the demonstration at the end of this month.

Specifically, for HHAs in North Carolina and Florida:

  • Providers may submit pre-claim review requests for billing periods beginning 8/31/20. During this transition period a provider does not have to request pre-claim review for each and every claim (if they want to participate in pre-claim review), only those they choose to submit.
  • Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review.
  • Claims submitted without going through the pre-claim review process will process as normal and will not be subject to a 25% payment reduction.
  • Claims may be subject to postpayment review in the future through the normal medical review process
  • Providers who have already made a choice selection do not need to take any further action if they choose not to participate.
  • CMS will reassess the phased-in approach in 60 days.

For Illinois, Ohio, and Texas:

  • Cycle 2 in Illinois and Cycle 1 in Texas will end on September 30, 2020.
  • Affirmation and claim approval rates will be calculated based on review decisions made between February 1, 2020 and September 30, 2020 for Illinois providers and between March 2, 2020 and September 30, 2020 for Texas providers.
  • Cycle 2 in Ohio will begin on August 31, 2020, as previously noted.
  • Claims submitted under Choice 1 without going through the pre-claim review process will not be subject to a 25% payment reduction until further notice but will be subject to prepayment review.

Source: CMS


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