MAC CGS Medicare has Posted Their Pre-Approval Process for the Manual Medical Review

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MAC CGS Medicare has Posted Their Pre-Approval Process for the Manual Medical Review

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Effective October 1, 2012, CMS will implement a phased Therapy Cap Exception (TCE) process. The implementation schedule is provided below. During this period, the 2012 therapy cap amounts will be $1880 for occupational therapy services and $1880 for the combined services for physical therapy and speech-language pathology. All requests for therapy services above $3,700 which are provided by a speech language therapist, physical therapist, or physician shall be approved or disapproved in advance. Settings include Part B SNF, CORF, ORF, private practices, rehabilitation agencies, and hospital outpatient departments. Occupational therapy provided above $3,700 shall also be approved in advance. On September 1, 2012, CMS mailed letters to specifically identified beneficiaries who have received therapy services over $1700 during the 2012 calendar year. This letter provided information to both the provider of services and the beneficiary regarding the $1,880 therapy cap and the exception process. CMS has also provided a list of providers (NPIs) who will be required to submit a request for pre-approval of a specific number of additional therapy treatment days, not to exceed 20 per discipline, each time the patient is expected to require more therapy then previously approved. This Therapy Cap Exception process will be implemented in phases:

  • Phase I: October 1, 2012 - December 31, 2012
  • Phase II: November 1, 2012 – December 31, 2012
  • Phase III: December 1, 2012 - December 31, 2012
Below is a link to the Therapy Cap Exception request form that providers will be required to complete for preapproval requests: In addition to the completed request form, the following information and documentation must also be submitted with each request:
  • Orders for the additional therapy services;
  • Licensure/certification of person who will perform therapy services or documentation of education/degree requirements are met if “qualified” but not licensed;
  • Justification; [For example, information in support of the assertion that the beneficiary’s functional and/or treatment needs involving ambulation and mobility cannot be adequately met unless Physical Therapy or Occupational Therapy is provided by a licensed physical or occupational therapist or physical or occupational therapy assistant working under the supervision of a licensed physical or occupational therapist and that these services can be reasonably expected to (1) achieve measurable and sustained functional gains for the beneficiary, or (2) establish a safe and effective maintenance program. In the case of Speech Language Pathology services, that the service recipient’s functional and/or treatment needs for communication/articulation/swallowing function, etc. require the services of a licensed Speech Language Pathologist and that these services can be reasonably expected to (1) achieve measurable and sustained functional gains for the beneficiary or (2) establish a safe and effective maintenance program];
  • Evaluation or reevaluation for medical necessity and certified Plan of Care;
  • Certification of the plan of care;
  • Progress reports;
  • Treatment notes;
  • Certification or recertification for therapy services;
  • Objectives and measurable goals and any other documentation required by the relevant Local Coverage Determination (LCD). (Objectives and goals should also state an estimate of a reasonable time frame in which the recipient could be expected to achieve the stated goals.)
  • A statement of the amount of additional services needed. A provider may request up to 20 additional treatment days of service per request
Upon completion of the review, providers will receive a decision letter. The decision letter will include a TCE identification number to be used to identify your claim when filed. To ensure proper processing of the claim for these services, insert the TCE identification number assigned to you in block 19 of the CMS 1500 claim form (comments fields/reserved field). Any claims submitted without pre-approval shall be subject to pre-payment review. Below is a link to the list of providers (NPIs) by phase who are required to submit a request for preapproval: Providers may submit their completed Therapy Cap Exception request form via fax to:
(615) 664-5946 Therapy Cap Part A OH (615) 664-5944 Therapy Cap Part A KY (615) 664-5973 Therapy Cap Part B OH (615) 664-5963 Therapy Cap Part B KY (615) 664-5993 Therapy Cap HHH
Or by mail to: J15 Part B Therapy CAP Requests P.O. Box 24357 Nashville, TN 37202 J15 HH&H Therapy CAP Requests P.O. Box 23468 Nashville, TN 37202 J15 Part A Therapy CAP Requests P.O. Box 23558 Nashville, TN. 37202 Also, you may refer to the provider education article at: http://www.cms.hhs.gov/MLNmattersArticles/ or http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODF_PNAHP.html