Payment: Are you prepared for the Preapproval process that started Oct 1, 2012?
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Are you prepared for the Preapproval process that started Oct 1, 2012?


Most of your questions can be answered by reviewing the information on the NGS website. The link is:
http://www.ngsmedicare.com/wps/poc/ngsmedicare?urile=wcm:path:/NGSMedicareContent/NGSMedicare/Review%20Process/Medical%20Review/Therapy%20Limitation%20and%20Manual%20Medical%20Review%20Process%20for%20Therapy%20Threshold&LOB=Part+A&CONTRACTTYPE=Title+XVIII+Providers


If this link does not work go to the NGS website at: www.ngsmedicare.com
Go to the Part A or Part B home page, under hot topics and click on “Therapy Limitation and Manual Medical Review Process for Therapy Threshold”.

Points of interest we have learned from our contacts at NGS:

  1. To find which Phase you are in go to the list at: https://data.cms.gov/dataset/Therapy-Provider-Phase-Information/ucun-6i4t Find your NPI. You are in phase III if not listed in either phase I or II.

  2. Check to see if your patient has reached the $3700 threshold on the NGS IVR by calling For Part A at (877)-567-7205 and for part B at (877)869-6504 or on Connex. (Remember that after October 1, 2012 this amount also includes services in Hospital OPD’s)

  3. Use the Preapproval form to request up to 20 treatment days. The form can be downloaded at: http://www.ngsmedicare.com/wps/wcm/connect/0e7308804ca306c786b98e555e90c49f/1319_0912_TherapyServicesPreapprovalForm_V2.pdf?MOD=AJPERES

  4. Submit all additional information needed for Medical Review staff to determine if continued services are Medically Necessary.

  5. Note that approvals are linked to specific Provider/NPI. Therefore if the patient may be seen by different members of the group or Hospital OPD, each possible treating provider must request a Prior approval.

  6. If members of a group or Hospital OPD have been assigned to different Phases, request preapproval on the earliest providers that may treat the patient in time for the assigned phase.

  7. You can submit Preapproval up to 2 weeks before the start of your assigned Phase.

  8. NGS has 10 business days to respond.

  9. If approval is granted you need to include the Preapproval tracking number on the claim (remember that the approval number is specific to the individual NPI). We have been instructed to add this number in Box 19 for claims filed in the 1500 format and in the Comment are on institutional submissions.

  10. Remember that you still need to include the KX modifier on these claims.

  11. For providers (in the same group or Hospital OPD’s) assigned to different Phases: If provider in phase I has received Preapproval and treats the patient on Oct 2, the claim goes in with the preapproval tracking number. If the patient is treated by a provider in Phase II on Oct 10, the claim goes in with the KX and no tracking number.

  12.  If a provider does not submit the necessary Preapproval and continues to treat the patient, these claims will be subject to Medical Review.  The information on the NGS website is very thorough. I highly recommend that you review it all esp. all the question and answers.

APTA also has a resource page on this process. Go to this link for APTA’s summary: http://www.apta.org/Payment/Medicare/TherapyCap/2012/Changes/

Catherine E. Anastasio, PT
NYPTA
Medicare Insurance Specialist

9/29/2012
 

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