As part of a July 26 update to its Q&As on the pre-claim review demonstration, CMS has made clear what agencies should do if they receive a provisionally affirmed decision but find later in the episode that the patient needs new services, such as therapy.
 
An initial pre-claim review request should be submitted after your agency has had enough time to evaluate the patient and determine what services will be required, CMS says.
 
“However, if later in the episode the beneficiary’s condition supports additional services that were not on the initial provisionally affirmed pre-claim review request, you would not need to submit an additional pre-claim review request for that episode,” CMS says. “CMS contractors (including Zone Program Integrity Contractors, Recovery Audit Contractors, and Medicare Administrative Contractors) may conduct targeted prepayment and post-payment reviews to ensure there is no evidence of fraud or gaming.”
 
Agencies in Florida, Illinois, Massachusetts, Michigan and Texas will participate in the demo.