Well, if you are anything like me, you are anxiously awaiting the famous Medicare Manual Review of Therapy Services process from your MAC/FI.  When are they going to post on their website on how to request approval for therapy treatment days once a threshold of $3700 is met?  Why haven’t they posted their instructions?  I know, I know ……..I know how you feel.

Every afternoon and well into the evening, I monitor each and every MAC/FI to see if they have posted their process.  You are probably thinking to yourself that I don’t have much of a life if that is all I do well into the evening!  Well, that may be true but I am committed to keeping our internal and external customers updated with the most current documentation compliance information.  It is my responsibility as Functional Pathways’ Director of Compliance to ensure that our therapists and therapist assistants are informed, trained, and well supported.  I value our relationships with our customers and am passionate about ensuring the services we provide are innovative and regulatory sound.  Ongoing self-improvement in our environment is crucial in every aspect of resident care and customer service.

CMS did provide us with uniform information that will be necessary when requesting treatment days once a resident has reached their $3700 threshold per cap.  This information can be found in CMS’ MLN Matters communication (MM8036).  Per CMSYou must send a request for approval to the MAC or legacy contractor in advance of providing service.  The MAC or legacy contractor will provide a mailing address and may provide a fax number where requests for pre-claim review can be submitted.  Pre-claim reviews will not be reviewed any sooner than 15 days before the start of each Phase for providers within that phase.” 

The following list of information has been taken directly from the MLN Matters Number: MM8036

The request must contain the following information:

  • Beneficiary Last Name
  • Beneficiary First Name
  • Beneficiary Middle Initial
  • Beneficiary Medicare Claim Number (HICN)
  • Beneficiary Date of Birth
  • Beneficiary Address and Telephone Number
  • Name of Provider Certifying Plan of Care
  • Address of Provider Certifying Plan of Care
  • Telephone and Fax Number of Provider certifying Plan of Care
  • Provider Number (National Provider Identifier (NPI)) of Physician/NPP Certifying Plan of Care
  • Name of Performing Provider
  • Address of Performing Provider
  • Performing Provider Number (NPI)
  • Telephone and Fax Number of Performing Provider
  • Number of treatment days requested
  • Expected date range of services
  • Date of Submission

A cover/transmittal sheet containing the following information and documentation must be sent:

  • Cover sheet
  • Justification
  • Evaluation or reevaluation(s) for Plan(s) of care
  • Certification(s) of the plan(s) of care, where available
  • Objectives and measurable goals and any other documentation requirements of the Local Coverage Determinations (LCDs)
  • Progress reports
  • Treatment notes
  • Any orders, if applicable, for the additional therapy services
  • Any additional information requested by the Medicare contractor

You may request preapproval of up to 20 treatment days of services.

The contractor will make a decision and inform (by telephone, fax, letter (if by letter, the letter must be postmarked by the 10th day)) the provider and beneficiary within 10 business days of receipt of all requested documentation.  If the contractor cannot make a decision within 10 days, the therapy will be considered approved.  The letter will indicate that the approval was made because of time constraints and not on the information provided to the contractor.

When the MACs/FIs post their individual process, I will be sure to share this information as quickly as possible.  If you are a Functional Pathways partner, you will be invited to join in on our training sessions.

There is a lot of great information in this MLN article and I encourage you to click on the link below and read the entire article.


Gina Henthorne


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