Pre-Claim Review

The two are often confused, and the distinction matters. Prior authorization requires approval before services are delivered; care waits on the payer. Pre-claim review happens after care begins: the patient is admitted, visits start, and the agency submits the review request during the billing period, before the final claim. Services and Medicare beneficiary access are not gated on the decision. What is gated is clean payment: a final claim submitted without an affirmed UTN goes through prepayment medical review instead of paying automatically. CMS designed it this way so that improper payment controls would not delay home health starts of care.

The request package mirrors the Medicare home health eligibility file. Reviewers look for:

• The signed plan of care and certification by the physician or allowed practitioner
• Face-to-face encounter documentation related to the primary reason for home health
• Documentation supporting homebound status and the need for skilled services
• Orders covering the services being billed
• Clinical detail for the period consistent with the OASIS assessment

The reviewer either affirms (fully or partially) or non-affirms the request. Non-affirmed requests come back with reasons, and the agency can correct and resubmit as many times as needed before the final claim.

An affirmed pre-claim decision generates a Unique Tracking Number, and that number must appear on the final claim. The UTN tells the claims system that the services were already reviewed, so the claim bypasses further complex medical review for those services and pays predictably. Under RCD, agencies that maintain high affirmation rates, generally 90 percent or better across a review cycle, also earn lighter-touch review options in subsequent cycles, such as spot-check review. Operationally, the UTN converts audit risk from an after-the-fact recoupment problem into an upfront checklist item, which is exactly the trade most CFOs prefer: the risk is resolved before revenue is booked, not years later.

The whole model rewards speed at the front of the episode. Requests should go in early in each 30-day period, leaving room for a resubmission cycle if the first attempt is non-affirmed. The most common bottleneck is physician paperwork: unsigned plans of care and missing face-to-face notes stall submissions until deadlines get tight. Watch for partial affirmations, where some services are affirmed and others are not; billing the non-affirmed services anyway invites denial. And do not let pre-claim workflow drift into a billing-only function. The documents reviewers reject are created by intake, clinicians, and physicians, so affirmation rates are a whole-agency metric, not a billing metric.