This demonstration applies to Inpatient Rehabilitation Facilities (IRFs) in California that provide rehabilitation services. Under this choice, all claims in the cycle will undergo post-payment review following standard IRF benefit rules. If an IRF does not select an initial option, this choice will be automatically assigned.

Step 1: Claim Submission

The IRF gathers all required documentation, including the Plan of Care, provides inpatient rehabilitation services, and then submits the claim to the MAC for processing.

Step 2: Additional Documentation Request

After the claim is received, the MAC will process it for payment and issue an Additional Documentation Request (ADR) to the IRF. The IRF must then provide all required medical records and supporting documents necessary for the review, which will determine the beneficiary's eligibility and the medical necessity of the services.

The IRF will have 45 days to respond to the ADR. If no response is received within 45 days, an overpayment will be initiated. The MAC will have 60 days to review the documentation and communicate a decision.