IRF Pre-Claim Review Process

This demonstration applies to Inpatient Rehabilitation Facilities (IRFs) in California that provide rehabilitation services. Information submitted will be reviewed by the MAC, and the decision (affirmative or non-affirmative) will be issued to the provider. A unique tracking number (UTN) will be assigned with each request.

The term requestor will be used throughout this page to describe the person or entity that submits the request.

Step 1: Pre-Claim Request Submission

Submit the IRF pre-claim request via one of the methods listed. If submitting request by mail or fax, it is suggested to use the Part A Authorization Request Coversheet that can be found on the Forms page.

View IRF Pre-Claim Review Required Documentation for detailed guidance on pre-claim review requirements.

Step 2: Submission Review

For initial requests, Noridian will notify the submitter and the beneficiary of the decision within two business days (excluding federal holidays). For resubmitted requests, submitted with additional documentation after a non-affirmed decision, the MAC will send notification to the IRF and the beneficiary within two business days (excluding federal holidays).

Step 3: Decision

Noridian will notify the submitter and beneficiary by phone within two business days and send a decision letter within 10 business days via the MAC provider portal, mail, or fax for all review decisions. IRFs using esMD will receive letters through the MAC portal (if enrolled for greenmail), as esMD does not currently support decision letters. A copy of the decision letter will also be mailed to the beneficiary.

Provisional Affirmative Decision: Preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare's coverage, coding, and payment requirements.

  • A provisional affirmative decision does not transfer if the beneficiary changes IRFs.
  • Only one IRF may request pre-claim review per stay. If readmitted within 3 days, a new request is not needed unless a separate claim will be filed. See 42 CFR Part 4124F 9, for further information on what constitutes discharge for billing and payment purposes.
  • Subsequent IRFs must submit a new pre-claim review request with required documentation.

Non-Affirmed Decision: Review shows Medicare IRF coverage requirements were not met.

  • The MAC will send a decision letter listing all reasons for non-affirmation to the IRF and the beneficiary.
  • For documentation errors where coverage criteria appear met, the MAC will call the IRF to provide education and encourage resubmission.

Incomplete Request: If a pre-claim review request is incomplete, it will be returned for resubmission, and both the IRF and the beneficiary will be notified.

  • The submitter may resubmit a complete package with all required documentation.
  • If a claim is submitted with a non-affirmed decision, it will be denied. Standard appeal rights apply, and the claim may be sent to secondary insurance.

Step 4: IRF Actions Based on Review Decision

Provisional Affirmative Decision:

  • Render services.
  • Submit pre-claim review request for eligible services.
  • Submit the claim with the UTN in the required field.
  • If all requirements are met, the claim will be paid and excluded from future MAC, RAC, or SMRC review (unless fraud is suspected).
  • Claims may still be reviewed by UPIC or selected for CERT sampling.

Non-Affirmed Decision:

Step 5: Claim Submission

The claim is submitted to Medicare for payment. This process improves compliance with Medicare program requirements to ensure that the right payments are made at the right time for IRF services.

Last Updated Feb 27 , 2026