The following document was developed based on questions and answers posed during our IRF RCD webinars and emails to members of our IRF RCD team.
You may refer to the Inpatient rehabilitation facility review choice demonstration (IRF RCD) webpage for details, links, and submission guidelines. Visit the CMS Review choice demonstration for inpatient rehabilitation facility services Frequently Asked Questions (FAQs) document for additional information.
1. Is using Novitasphere the only way to make our review choice selection?
Yes, IRFs are required to make the review choice selection using the Novitasphere portal. 2.
How will we receive important updates on the IRF RCD? If something is added or changed on the IRF RCD webpage, how will the IRF be notified?Information regarding the IRF RCD program, including updates, will be published to the
IRF RCD webpage. Important updates to the IRF RCD program will be communicated by Novitas in one of two ways depending on IRF RCD provider participation status:
IRFs currently participating in the IRF RCD will receive email communications to the contacts designated by the IRF and reported to Novitas during the pre-implementation period.
To request additional recipients, submit an email request to
Education@novitas-solutions.com identifying the name and NPI of the IRF facility and the name and email address of the additional contacts.
IRFs currently not-participating in the IRF RCD program will receive updates via the Novitas weekly email listserv.
3. How is the patient notified of the IRF RCD?
4. How do I know what documentation to include in a pre-claim review or postpayment review?
The following links include the required documentation that supports medical necessity requirement as outlined in the checklists:
5. Does IRF RCD apply to a patient with Railroad Medicare?
Yes, the IRF RCD applies to patients with Railroad Medicare. The jurisdictional A/B MACs process hospital and SNF facility claims for both Medicare and Railroad Medicare and Railroad Medicare is not an exclusion for IRF RCD.
6. Are informational only claims subject to RCD?
No. The only claims that are subject to the RCD are standard Medicare FFS admissions, regardless of whether an informational-only claim must be submitted to the Medicare FFS MAC for administrative purposes.
7. What do I do if I received an ADR letter for a Medicare Advantage claim?
If the claim submitted was for Medicare Advantage, the provider should notify Novitas. The claim will be released and process as normal and the ADR letter can be discarded.
1. Does Novitas have a definition for "rehabilitation physician"? That is, what type of board certification and/or ongoing education should a physician have to meet the definition of "rehab physician?
Rehabilitation physician means a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation. Please refer to
42 CFR §412.622(C).
2. Can you clarify what is meant by "the preadmission screening (PAS) is conducted by a clinician designated by a rehabilitation physician?
A rehabilitation physician will designate a clinician who has been trained accordingly, to review information and /or assess a patient to generate all the clinical information needed for a prescreen. Thereafter the physician reviews the prescreen to determine if the patient qualifies for the IRF setting and signs to verify their approval.
1. Can more than one contact be added to the PCR request?
The PCR request cover sheet has space for one contact. However, additional contacts may be included in the rest of your documentation.
2. If the contact person on the PCR request cannot be reached, what steps are taken? Will you call any additional contacts on file?
A contact name and phone number will be left on voicemail. The decision nor any Protected Health Information
(PHI) will not be left in voicemail. If the primary contact is unreachable, then an attempt will be made to reach out to additional contacts provided with the PCR request. 3. Will PCR decision details be left on voicemail if it is indicated it is a secure protected voicemail?
No, a contact name and phone number will be provided, but no PHI.
4. What will be the hours that the decision phone calls will be made?
The decision phone calls will be made during normal business hours between 8:00 a.m. and 5:00 p.m. ET Monday through Friday. If the contact person has particular hours of availability, this should be noted on the PCR request.
5. Will the decision be posted in Novitasphere in addition to being mailed? If so, when will it be available?
If the PCR request was submitted via the Novitasphere portal, then a copy of the decision letter will be posted in the Novitasphere portal mailbox in addition to being mailed. The decision letter will be made available in the portal within the 2 to 10 business day timeframe. Just as letters are allotted for 10 business days per CMS guidelines, the same timeframe will apply for Novitasphere. Remember, verbal decisions will be communicated within 2 business days.
6. What address will the PCR request decision letter be mailed to?
The decision for a PCR request will be mailed to the address provided on the PCR request.
7. If an IRF receives a non-affirmation on a PCR request and submits a resubmission, will it be the same nurse reviewer who reviews the resubmission?
It will be a member of the IRF medical review team and not necessarily the same nurse reviewer.
8. How much time do we have to submit a resubmission after we receive a non-affirmation?
A resubmission PCR can be submitted any time after receiving a non-affirmation if it is submitted prior to the final claim submission. Providers can submit a resubmission PCR an unlimited number of times prior to the final claim being submitted. Each submission decision will receive a unique transaction number (UTN) and the same decision timeframes apply: 2 business days via telephone and 10 business days via mail.
9. What address is used for an additional documentation request (ADR) for a prepayment review?
An ADR for a claim stopped for prepayment review will be mailed to the address listed in PECOS as the Main/Primary Hospital Location address which is the master address in FISS. It is important to make sure your address information is up to date. To update your address, complete a change of information enrollment application:
Paper-based Medicare Enrollment Application - Institutional Providers (CMS-855A) 10. How am I notified of a decision for a prepayment review?
Novitas will have 30 days to review the documentation and communicate a decision. The decision will not be a letter rather the claim will process and pay if medical necessity is met, or the claim will process and deny if medical necessity is not met. Denied claims will have
appeal rights. You can check the status through normal processing procedures such as through the portal, IVR, or via your remittance advice. For denied claims, you will have appeal rights. If you receive a claim rejection, you may correct and resubmit the claim.
11. What is the format of the UTN?
The UTN format is 0LA0000000XXXX. Note the UTN only has number ‘0’ – not letter ‘O’.
12. Will you provide the UTN on the phone call or will it only be listed in the letter?
The UTN will be provided in the decision letter. Even through the UTN can be provided verbally, due to the length and character repetition, we encourage the providers to wait on the letter.
13. Where on the claim does the UTN get reported?
Electronic claims:
First 14 bytes of the treatment authorization field at the loop 2300 REF02 (REF01=G1) segment for the ASC X12 837 claim
Fiscal Intermediary Standard System (FISS)/ Direct Data Entry (DDE):
Tab to second field of the treatment authorization field (positions 19-32) on DDE Page 05 (MAP1715)
Note: if entered in the first field (positions 1-18), FISS changes to all zeros and without the UTN
14.
Will I receive a new UTN for each PCR resubmission? If so, which UTN do I use on my final claim submission?Yes, a different UTN will be provided for each PCR request submission, whether it’s provisionally affirmed or non-affirmed. Novitas will list the UTN on each decision letter. Therefore, a PCR that is resubmitted multiple times will have multiple UTNs. The provider should use the most recent UTN when submitting claim final claim for payment.
15. Is the IRF physician referenced in the cover sheet intended to be the physician that approves the admission in the PAS or the attending physician once the patient is admitted?
The physician on the cover sheet does not have to be the physician that approved the preadmission. The physician that reviews and approves the PAS does not have to be the admitting physician.
16. When you fill out the PCR request form, who is the physician? The attending physician or the physical medicine and rehabilitation (PMR) physician? We have a PMR as a consultant in some units.
The admitting or PMR physician can fill out the form.
17. What if we send a PCR request for a patient that we find out later is not needed, what happens to that case?
The provider can call to cancel the case if it has not been completed or is no longer needed. Otherwise, if the review was completed the review would stand and be included in the affirmation rate calculation at the end of the cycle.
18. Are interrupted stays, short stays, and short stay transfers included in the IRF RCD program?
Interrupted stays:
Yes, interrupted stays of less than 3 days are included in the IRF RCD. In order to avoid a non-affirmation, the IRF should only submit PCR requests once they have all required documentation. If the beneficiary returns to the acute care facility before the PCR request has been submitted, the IRF should wait to submit the request until they have the rest of the documentation.
Aside from adding the UTN to the claim, the IRF’s billing practices would not change or be impacted relative to the IRF RCD program. Providers should ensure that Occurrence Span Code 74 is present on the claim if there is an interrupted stay less than 3 days. If the patient returns to the IRF by midnight of the 3rd day, the bill continues under the same CMG. CWF will need to edit to ensure that if another IRF bill comes in during the interrupted stay, it is rejected, as it should be associated with the original CMG (Medicare Claims Processing Manual – 100-04, Chapter 3, Section 140.3.1 – Shared Systems and CWF Edits). If the interruption is greater than 3 days, the bill should be considered a discharge.
Short stays:
No, short stays with CMG A5001 are not included in the IRF RCD. Under the IRF PPS, if a patient is in an IRF for 3 days or less, they may be eligible for and receive the IRF short stay payment (CMG A5001). A UTN is not needed if the claim is processed with CMG A5001. The IRF’s billing practices would not change or be impacted relative to the IRF RCD program.
Short stay transfers:
Yes, these stays are included in the IRF RCD. Short stay transfers are transfers from an IRF to another institutional setting prior to the average length of stay given the patient's Case-Mix Group and comorbidities. A patient can be transferred to another IRF, a short-term, acute-care prospective payment hospital, a long-term care hospital as described in § 412.23(e), or a nursing home that qualifies to receive Medicare or Medicaid payments. A UTN is needed for this type of claim and the IRF’s billing practices would not change or be impacted relative to the IRF RCD program in accordance with 42 CFR 412.624(f)(2). Reference:
1. What address is used for the ADR and the postpayment review decisions?
An ADR for postpayment review and the postpayment review decision will be mailed to the address listed in Provider Enrollment, Chain, and Ownership System (PECOS) as the main/primary hospital location address
which is the master address
in FISS. It is important to make sure your address information is up to date. To update your address, complete a change of information enrollment application: Paper-based Medicare Enrollment Application - Institutional Providers (CMS-855A) 2. Will my postpayment review decision be available in Novitasphere?
A copy of the decision letter will be available in Mailbox feature under Retrieve Documents in Novitasphere if the ADR response was submitted through the portal.
3. Can I submit review documentation on a CD/DVD?
Providers may submit review documentation via a password protected CD/DVD via mail.
Subject: CD/DVD password, provider name.
Body of email: Provider name, Provider Transaction Access Number (PTAN) and the DCN/ICNs applicable to the CD/DVD, and the password.
If you are responding to multiple MR ADR requests, clearly separate the documentation for each claim.
1. How will the IRF's affirmation rate be calculated?
The affirmation rate will be calculated as follows:
Number of Affirms / Last Instance For Each Unique Beneficiary Requests [unique combination of PTAN / MBI / Admission date] = IRF RCD Affirmation Rate
PCR affirmation rate clarifications:
Only PCRs where a decision is made (affirmed or non-affirmed) are included in the calculation. Rejections or dismissals are not part of the calculation and do not have an impact on the affirmation rate.
If an initial PCR submission is non-affirmed and the resubmission is also non-affirmed, this is only counted as one (1) non-affirmation when the facility, beneficiary, and admission date are the same on the PCR request.
If multiple PCR submissions are non-affirmed, but the request is ultimately affirmed, this is only counted as one (1) affirmation when the facility, beneficiary, and admission date are the same on the PCR request, regardless of the number of previous non-affirmations.
If the PCR request is not affirmed by the end of the 6-month cycle, the most recent review decision will be counted in the overall affirmation rate.
If an initial PCR submission or resubmission is not affirmed by the end of the 6-month cycle and is counted as a non-affirmation in the overall affirmation rate for that cycle, but the request is resubmitted and ultimately affirmed during the next cycle, the affirmation will be counted in the overall affirmation rate for the next cycle.
2. How long is a review cycle?
A review cycle is 6 months; however, IRFs will continue to submit reviews based on the current review choice until the next cycle review start date.
3. How will the end of cycle affirmation and approval rates be communicated?
The end of cycle affirmation and approval rates will be communicated through postal mail. Additionally, Novitasphere will have a Cycle Stats feature that will show data based on your choice selection for each cycle.
1. What is the acceptable document format for upload in Novitasphere for IRF RCD reviews?
The acceptable document formats are TIFF and PDF. Password protected documents cannot be processed and will not be accepted.
2. Can we submit documents in Novitasphere on weekends and holidays?
Novitasphere is available 24 hours a day, 7 days a week, except for routine scheduled maintenance, which occurs:
Daily from 4 - 4:30 a.m. ET
Sunday evenings from 5 - 11 p.m. ET
Wednesday evenings from 8 - 10 p.m. ET
During these times, one or more features, or the portal itself, may not be accessible. Any other scheduled maintenance will be posted to our
website.
1. Does IRF RCD apply if Medicare is secondary?
The IRF RCD will apply to beneficiaries for which Medicare is the secondary payer. Please review the
CMS IRF RCD operational guide which addresses Medicare Secondary Payer (MSP) situations. The IRF can submit a PCR request prior to submitting the claim to the primary insurer. If the IRF does not submit a PCR request prior to submitting the claim to the primary insurer, when the IRF submits to Medicare as the secondary payer, the claim will be stopped for prepayment review. The beneficiary must meet all IRF benefit requirements. A claim is required to be submitted to Medicare whether the primary insurer paid the claim in full, partially paid, or denied the claim. For more information on Medicare secondary payer, refer to the
Provider specialty: Medicare secondary payer (MSP).
2. What happens when the patient’s insurance changes during their stay in rehab or transitions from acute to rehab (insurances are not always updated in real time)? For example, what if Medicare is secondary due to an accident? What if the benefits exhaust? Are we responsible for doing the pre-claim review? When should the PCR be completed- before or after we submit to the primary insurance?
Providers are to submit a claim the primary insurer before submitting a claim to the Medicare as secondary. Keep in mind that all IRF stays during cycle 1 will receive 100% review, regardless of if Medicare is primary or secondary. If the IRF chose PCR and they do not go through the PCR process prior to submitting a claim because they are thinking the patient belongs to another payer source, when the claim is filed to Medicare it will be stopped for prepayment review.
3. What if the patient did not have Medicare at the time of admission but becomes entitled during the stay?
If the IRF chose PCR for their review and the patient becomes entitled to Medicare during the stay they can submit either a PCR request if a claim has not yet been submitted since they can be done retroactive or submit the claim and it will be stopped for prepayment review.
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