Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) period for the COVID-19 pandemic?
A. Yes, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.
Q. Is CMS waiving signature requirements on proof of delivery slips in response to the COVID-19 pandemic, for Dates of Service (DOS) within the PHE for the COVID-19 pandemic?
A. Yes, given the nature of the pandemic and the inability to collect signatures during this time, CMS will not be enforcing the signature requirement. Typically, Part B drugs and certain Durable Medical Equipment (DME) covered by Medicare require proof of delivery and/or a beneficiary’s signature. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.
Q. Is CMS pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model?
A. Yes. Effective March 29, 2020, certain claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model will be paused in the model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia until the PHE for the COVID-19 pandemic has ended. During the pause, claims for repetitive, scheduled non-emergent ambulance transports submitted on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic in these states will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.
Q. The model is currently scheduled to end on December 1, 2020. Given this pause, will CMS extend the model beyond that date?
A. At this time, CMS is not planning an extension beyond December 1, 2020. If this did occur, CMS would provide proper public notice. Further, the model will not be expanded in any other state during the PHE.
Q. How does this pause in the model affect a determination as to whether the model meets the criteria to be expanded nationwide, as provided under section 1834(l)(16) of the Social Security Act, and any next steps for expansion?
A. The pause in the model does not affect the efforts to expand the model nationwide as provided under section 1843(l)(16). CMS will continue its efforts to prepare for expansion after the PHE for the COVID-19 pandemic has ended.
Q. How does this pause in the model affect evaluation of the model?
A. The evaluation of the model will take into consideration the pause for the PHE for the COVID-19 pandemic. Those claims will be reviewed through postpayment review and will still be factored into the evaluation.
Q. Is CMS pausing the Review Choice Demonstration for Home Health Services?
A. Yes. Effective March 29, 2020, certain claims processing for the Review Choice Demonstration (RCD) for Home Health Services will be paused in Illinois, Ohio, and Texas, until the PHE for the COVID-19 pandemic has ended. During the pause, the MACs will process claims submitted prior to the emergency period under normal claims processing requirements. Claims for home health services furnished on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic in these states will not be subject to the review choices made by the home health agency under the demonstration. However, the MAC will continue to review any pre-claim review requests that have already been submitted, and providers may continue to submit new pre-claim review requests for review during the pause. Claims that have received a provisional affirmative pre-claim review decision and are submitted with an affirmed Unique Tracking Number (UTN) will continue to be excluded from future medical review. Home health agencies participating in pre-claim review may submit their claims without requesting such approval from the MAC and claims submitted without a UTN will not be stopped for prepayment review and will not receive a 25% payment reduction. HHAs participating in the other review choices (prepayment or postpayment review) will not receive Additional Documentation Requests (ADRs) during the pause, and ADRs that were issued prior to the PHE will be released and processed as normal. Following the end of the PHE for the COVID-19 pandemic, the MAC will conduct postpayment review on claims subject to the demonstration that were submitted and paid during the pause.
The demonstration will not begin in North Carolina and Florida on May 4, 2020, as previously scheduled. CMS will provide notice on its demonstration website rescheduling the start of the demonstration, once the PHE has ended.
Q. The demonstration is currently scheduled to end on May 31, 2024. Given this pause, will CMS extend the demonstration beyond that date?
A. At this time, CMS is not planning an extension beyond May 31, 2024. If this did occur, CMS would provide proper public notice