Inpatient Rehabilitation Facility Pre-Claim Review Process

Under the Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD), providers who select Choice 1: Pre Claim Review (PCR) must submit documentation for 100 percent of IRF admissions before submitting the final claim. PCR verifies that coverage, payment and coding requirements are met in advance.

Although services may begin prior to sending the PCR request, the provider must receive the PCR decision before filing the final claim. IRFs receive detailed feedback with each submission and may resubmit an unlimited number of times before the claim is submitted. 

A unique tracking number (UTN) must be included on the final claim. Claims submitted without a UTN will be subject to a prepayment additional documentation request (ADR).

Preparing Your PCR Request

A PCR request can be submitted any time before the final claim. Please complete the IRF Pre-Claim Review Submission Form for IRF PCR Submissions. Each request must include core identifying information for the patient, physician and IRF, along with a contact person. Providers may submit through mail, fax, the eServices portal or esMD. Palmetto GBA will respond using the same method when possible.

The PCR request should include all documents and information that support medical necessity and all eligibility requirements for the beneficiary needing the applicable level of IRF services. Please review the Pre-Claim Review IRF RCD Checklist (PDF) to ensure all necessary documentation is submitted to Palmetto GBA.

Submitting and Receiving PCR Decisions

Palmetto GBA will communicate a provisional affirm or non-affirm decision by phone within two business days (excluding federal holidays). Palmetto GBA considers the business day to end at 5 p.m. ET. Requests submitted at or after 5 p.m. are treated as received the next business day, which becomes the start date for the two business-day PCR review period. 

A written decision will follow within 10 business days through eServices, mail or fax for both initial and resubmitted requests. IRFs using esMD will receive letters through eServices (if enrolled for greenmail), as esMD does not currently support decision letters. A copy of each decision letter is also mailed to the beneficiary.

Provisional Affirmative Decision

A provisional affirmation does not guarantee payment; rather, it indicates that the claim is expected to meet Medicare’s coverage, clinical documentation, and technical requirements upon submission. An affirmed determination represents a preliminary assessment that the forthcoming claim is likely compliant based on the documentation reviewed. Upon receipt of provisional affirmation, the provider will be issued a UTN, which must be included with the final claim submission.

Non-Affirmed Decision

A non-affirmed decision indicates that the IRF services, as submitted, do not meet Medicare’s requirements for payment. This outcome may result from insufficient documentation or a determination that the requested services are not medically necessary. Providers may make unlimited resubmissions with corrected or additional documentation prior to claim submission. If a claim is submitted to Palmetto GBA with a non-affirmed decision and its associated UTN, the claim will be denied, and the standard claims appeals process will apply.

A UTN is assigned to every PCR request, regardless of whether the decision is provisionally affirmed or non-affirmed. Palmetto GBA includes the UTN on each decision letter and provides it during the decision phone call. 

Submitting the Final Claim

The final claim is submitted to Medicare for payment. This step supports compliance with Medicare program requirements and helps ensure that IRF services are paid accurately and appropriately.

Resources

• IRF RCD Operational Guide (PDF)
• IRF RCD Frequently Asked Questions (PDF)
• IRF RCD Choice Selection Definitions and Processes
• Inpatient Rehabilitation Facility Review Demonstration Required Documentation for a Pre-Claim Review Submission
• IRF RCD Pre-Claim Review Resubmissions