So, we are approaching December 1st.  Do you see light at the end of the tunnel for the Manual Medical Review?  Well, if you were in phase 1, you have been working diligently to obtain pre-approval of therapy visits for almost two full months now.  And if you were in phase 2, you are probably still encountering bumps in the road.  So, phase 3 providers—it’s your turn.

Phase 3 providers are able to submit requests as early as Friday, November 16th which is 15 days prior to your phase in date of December 1st.

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.  And don’t forget to complete your MAC required pre-approval request form!

The MACs will have 10 business days to provide a decision and if the MAC fails to provide a decision to the provider, the request for addtional therapy visits is deemed approved.  If your request is not approved, the MAC must provide a detailed explanation why.

Rollout has occurred in three phases to avoid the MACs from being overwhelmed.

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. Fax each request separately
  6. Make sure all of the pages are transmitted in the fax
  7. Keep your fax confirmation report

If you have any questions regarding your pre-approval decision letter, CMS recommends working directly with your MAC to resolve any issues.


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