IRF Pre-Claim Review Decisions and Claim Submission Instructions - JE Part A
IRF Pre-Claim Review Decisions and Claim Submission Instructions
This section explains how to submit Inpatient Rehabilitation Facility (IRF) claims based on the outcome of a pre-claim review request.
When This Applies:
A pre claim review was requested and provisionally affirmed
What Happens to the Claim:
Claim may be submitted for payment with the assigned UTN
When This Applies:
A pre-claim review was requested and non-affirmed
What Happens to the Claim:
Claim must still be submitted but will be denied; appeal rights apply
When This Applies:
Claim submitted without a pre-claim review after selecting Choice 1
What Happens to the Claim:
Claim is held for prepayment medical review
Provisional Affirmative Decision
Applies when a pre-claim review is requested and a provisional affirmative decision is received.
Claim Submission Requirements
- Include the Unique Tracking Number (UTN) from the decision letter.
- Each IRF stay is assigned a unique UTN.
Electronic Claims (ASC X12 837):
- Enter the UTN in positions 1-18.
- FISS will move the UTN to positions 19-32 and autofill zeros in the first field.
- The Medicare Treatment Authorization field must contain blanks or valid Medicare data in the first 14 bytes at Loop 2300 REF02 (REF01 = G1).
Other Claim Submissions:
- Enter the UTN in the second field (positions 19-32).
- Do not enter data in the first field.
- FISS will convert the first field to zeros.
- The claim will process without the UTN present in the first field but will still edit for the IRF UTN.
Final Claim Submission
- Submit the final claim with:
- The pre-claim review UTN
- The rendering provider's NPI
IRF Change During the Benefit Period
If the IRF changes during the benefit period and the new IRF did not submit a pre-claim review request, the claim will undergo complex medical review. The new IRF must submit all supporting medical documentation.
Non-Affirmed Decision
Applies when a pre-claim review is requested and a non-affirmed decision is received.
Claim Submission Requirements
- Include the UTN from the non-affirmed decision letter.
Electronic Claims (ASC X12 837):
- Enter the UTN in positions 1-18.
- FISS will move the UTN to positions 19-32 and autofill zeros in the first field.
- The Medicare Treatment Authorization field must contain blanks or valid Medicare data in the first 14 bytes at Loop 2300 REF02 (REF01 = G1).
Other Claim Submissions:
- Enter the UTN in the second field (positions 19-32).
- Do not enter data in the first field.
- FISS will convert the first field to zeros.
- The claim will process without the UTN present in the first field but will still edit for the IRF UTN.
Final Claim Submission and Payment
- Submit the final claim with:
- The pre-claim review UTN
- The rendering provider's NPI
- Claims associated with a non-affirmed pre-claim review decision will be denied.
- Standard appeal rights apply, and the claim may then be submitted to secondary insurance, if applicable.
Pre-Claim Review Not Requested
Applies when a claim is submitted without a pre-claim review after the provider selected Choice 1 (Pre-Claim Review).
- The claim will be held for prepayment medical review.
- Additional documentation may be requested through an Additional Documentation Request (ADR).
