Available For: Part A Inpatient Rehab Facility (IRF) Providers in California

IRF providers may submit a request for pre-claim services review by completing the Pre-Claim Request Form.

Note: If you selected post-payment as your review choice, the claim must be submitted through your facility's normal billing process. An additional documentation request will be issued at that time.

Choose Prior Auth/Pre-Claim from the Main Menu and then the Submit New PA/Pre-Claim tab.

Submit New Pre-Claim Request

Provider/Supplier Details

Directions: Choose the Provider/Supplier Details of the Inpatient Rehab Facility for which the request is being submitted. The Unique Tracking Number (UTN) used for billing will be associated with this facility information. To view the request after submission, your NMP account must be registered under the IRF for which the request is submitted.

• TIN or SSN
• NPI
• PTAN
• Program - Ensure MEDA is selected

Prior Authorization Type

Directions: Choose "IRF RCD"

Physician/Provider Details

Directions: Enter the information for the rehabilitation provider that will perform services during the IRF stay.

• Provider Name
• Provider PTAN
• Provider NPI
• Provider Address
• Provider City
• Provider State
• Provider Zip
• Provider Fax Number (Not Required)

Beneficiary Details (As it appears on Medicare Card)

Directions: Enter the beneficiary information as it appears on their Medicare card. Ensure all submitted medical records have the same spelling and date of birth as entered.

• Medicare Number
• First Name
• Last Name
• Date of Birth
• State of Residence (Not required)

Requestor Details

Directions: The requestor is the individual submitting the request (e.x. office manager or claim specialist). A Clinical reviewer will contact the requestor once a determination has been made.

• Requestor Full Name/Provider Name
• Requestor Phone
• Requestor Email Address
• Requestor Fax Number
• Requestor Address
• Requestor City
• Requestor State
• Requestor Zip

Facility Details

Directions: Enter the IRF facility information as entered in the Provider/Supplier Details section. These fields must match.

• Facility Name (Auto-populated)
• Facility Address
• Facility City
• Facility State
• Facility Zip
• Facility NPI: (Auto-populated)
• Facility PTAN: (Auto-populated)

Prior Authorization Request Details

• Admission Date: Date patient was admitted to facility
• Type of Bill - Enter 11X - Hospital Inpatient
• Is this an Initial Request or a Resubmission - Select Initial Request or Resubmission. If Resubmission, enter Previous UTN.

Upload Supporting Document

Ensure all medical records contain the correct beneficiary's name and date of birth.

Upload Requirements:

Maximum File Size: 70 MB

Supported Formats: GIF, JPG, JPEG, TIF, TIFF, DOC, DOCX, XLS, XLSX, PDF

File Name Limit: 40 characters (use a descriptive name to identify the document and its purpose)

Once all documentation is attached, select Submit.

Once the request has been submitted, a Reference Number will be assigned. Additional documentation may be uploaded 15 minutes after submission to allow the request to be processed. To upload additional documentation or check status, perform a Pre-Claim Status Inquiry.

To view the status or decision of a Pre-Claim Request, perform a Pre-Claim Inquiry. Status inquiries may be performed after 15 minutes of submission.

Pre-Claim Status Inquiry

Part A IRF users may check the pre-claim request status, view reviewer notes, and add or view related documents, including the decision letter. Note: Allow 15 minutes after initial submission before performing a status inquiry.

Inquiry

Provider/Supplier Details

Directions: Select the same provider information used during submission in the Provider/Supplier Details Your NMP account must be registered with the IRF details to view the submission.

• TIN or SSN
• NPI
• PTAN
• Program - Ensure MEDA is selected

Beneficiary Details (As it appears on Medicare Card)

Directions: Enter the beneficiary information used on the original request.

• Medicare Number
• First Name
• Last Name

Prior Authorization Request Details

• HCPCS - Enter A0101.

Choose Submit Inquiry.

Response

The following details will be available:

• Unique Tracking Number (UTN)
• Reference Number
• Receipt Date
• Complete Date
• Review Status
• Decision
• Medical Review Notes
• Related Documents - View documents associated with the request. This includes the decision letter. Additional documentation may be uploaded 15 minutes after submission.