Inpatient Rehabilitation Facility Review Choice Demonstration Choice Selection

Published 07/10/2023

Choice Selection
The first milestone for Inpatient Rehabilitation Facility (IRF) providers during the Review Choice Demonstration (RCD) is to select between pre-claim or postpayment reviews. The selection period will start on July 7, 2023, and end on August 6, 2023. Alabama IRF providers will make their review choice selection on the Palmetto GBA provider portal. If a choice is not selected, the IRF will default to Choice 2: Postpayment Review.

Choice 1: 100% Pre-Claim Review (PCR). PCR is a process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment. PCR helps make sure that applicable coverage, payment and coding rules are met before the final claim is submitted.

  • IRF must request PCR for all stays
  • Claims submitted without PCR will undergo prepayment review
  • Unlimited resubmissions are allowed for non-affirmed decision prior to submission of the final claim for payment
  • Claims associated with a provisionally affirmed request will not undergo further medical review, except in limited circumstances
  • An affirmation rate is calculated every six (6) months

Choice 2: 100% Postpayment Review (Initial Default). Claims are reviewed after final claim submission. IRF submits claims for each admission.

  • Each claim is processed and paid per CMS regulations
  • MAC sends Additional Documentation Requests (ADRs) and follows CMS’ postpayment review regulations
  • An approval rate is calculated every six (6) months

Cycle 1 Review Dates
The first cycle of review dates for this demonstration is August 21, 2023, through February 29, 2024.

End of Cycle Rate Calculation 
IRFs will be evaluated over a six-month review cycle. If the End of Cycle rate meets or exceeds the target rate of 80% (based on a minimum of 10 submitted pre-claim review requests or claims) in the first review cycle, the IRF may select one of three subsequent review choices:

  • Choice 1: Pre-Claim Review;
  • Choice 3: Selective Postpayment Review: A statistically valid percentage of random claims that are reviewed every six (6) months based upon the previous six (6) months of claim volume; or
  • Choice 4: Spot Check Review: A random sample selection of 5 percent of an IRFs submitted claims, based on their previous six-month claim volume for pre-payment review, to ensure continued compliance

If an IRF does not make a subsequent review choice, it will default to Choice 3: Selective Postpayment Review. 

Note: IRFs with less than the target affirmation rate or who have not submitted at least 10 requests/claims must again choose from one of the initial two options.

Resources


Was this article helpful?