October 9, 2012 News

Medicare Preapproval Changes Are Here

If you are a speech-language pathologist who provides services to Medicare-eligible clients, you must now request Medicare pre-approval to continue to provide services to beneficiaries whose combined speech-language pathology and physical therapy services in 2012 have exceeded $3,700 as of Oct. 1.

You also may have received notification of your assigned phase for manual medical review of those beneficiaries' claims.

So, now what do you do?

Step 1

The manual review process includes three phases, each with different implementation dates. Check which phase your private practice or facility has been assigned. The pre-approval process begins:

  • Oct. 1 for providers in Phase 1
  • Nov. 1 for providers in Phase 2
  • Dec. 1 for providers in Phase 3

Step 2

Your Medicare Administrative Contractor (MAC) can tell you:

  • Which patients may require pre-approval for continued services.
  • The MAC's process for submitting pre-approval requests.

For telephone numbers and links to all the Medicare Part B MACs, visit the ASHA website. Providers may request pre-approval for up to 20 treatment days of services for patients who are at or near the $3,700 cap.

Preapproval Requirements

Regardless of the MAC's process, the Centers for Medicare and Medicaid Services (CMS) requires that pre-approval requests include, at a minimum:

  • Beneficiary name, Medicare claim number, date of birth, address, and telephone.
  • Name, provider number, address, and telephone of the physician/nonphysician provider certifying the plan of care.
  • Name, provider number, address, and telephone of the facility or private practice providing treatment.
  • The number of treatment days requested, expected date range of service, and date of submission.
  • Medical justification for continued treatment, including evaluation and/or re-evaluation for the plan of care (POC); certification of the POC; objectives and measureable goals and any other document requirements of the local coverage determination; progress reports and treatment notes; any orders for the additional treatment.

If pre-approval is denied, you may submit a new pre-approval request only if you have new or additional information to include in the request.

Why the New Regs?

The Middle Class Tax Relief and Job Creation Act of 2012, passed by Congress in February, mandates CMS to conduct a "manual medical review" of claims that exceed $3,700 on or after Oct. 1 (The ASHA Leader, July 3, Aug. 28). The manual medical review is in effect Oct. 1 through Dec. 31, and may or may not be mandated for 2013.

Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.

Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.

cite as: Satterfield, L.  & Kander, M. (2012, October 09). Medicare Preapproval Changes Are Here. The ASHA Leader.


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