Phase 2 providers are approaching their debut for submitting their pre-approval requests for part B therapy residents who have met or will meet the $3700 threshold for OT and $3700 threshold for PT/ST.  You may have already submitted your pre-approval requests in preparation for November 1st or you are preparing your pre-approval packets.

Providers can make requests in up to 20-day increments and will need to submit the therapy plan of treatment/updated plan of treatment, therapy orders, daily therapy notes, and weekly therapy notes to the MAC for review.

The MACs will have 10 days to provide pre-approval and if the MAC fails to provide a decision to the provider, the request for additional therapy visits is automatically approved.  If the claim is denied, the MAC must explain in detail why.

Rollout will occur in three phases to avoid the MACs from being overwhelmed.  CMS will mail a letter by the end of August to every provider that billed therapy in 2011 stating which phase the provider will be in.  The phases are below

Phase 1:           October 1, 2012 through December 31, 2012

Phase 2:           November 1, 2012 through December 31, 2012

Phase 3:           December 1, 2012 through December 31, 2012

The manual review process applies to all Medicare Part B outpatient therapy settings and providers.  These include: private practices, skilled nursing facilities, home health agencies, outpatient rehab facilities, comprehensive outpatient rehab facilities (CORFs), and hospital outpatient departments.  Critical Access Hospitals are excluded.

Tips when submitting your pre-approval requests:

  1. Ensure the entire pre-approval request form is completed
  2. Ensure the resident’s name and Medicare number is accurate
  3. Ensure the physician’s NPI number is accurate
  4. Include all necessary therapy supportive documentation per the MAC process
  5. Submit one fax per request
  6. Make sure all of the pages are transmitted in the fax
  7. Keep your fax confirmation
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