COVID-19 Provider Burden Relief Frequently Asked Questions — CMS (July 2020)

Summary

CMS Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs), dated July 2020. It states that on March 30 CMS suspended most Medicare Fee-For-Service medical review because of the pandemic and expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. It states that CMS will not enforce signature requirements on proof of delivery slips and will not review non-emergency ambulance transports for practitioner signature compliance during the PHE, absent indication of fraud or abuse. It states that certain Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model requirements were paused effective March 29, 2020, with full operations resuming on or after August 3, 2020, and that the model is scheduled to end on December 1, 2020.

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                                                                                       July 2020


     Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked
                                  Questions (FAQs)


Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the
Public Health Emergency (PHE) for the COVID-19 pandemic?
A. On March 30 CMS suspended most Medicare Fee-For-Service (FFS) medical review because
of the COVID-19 pandemic. This included pre-payment medical reviews conducted by Medicare
Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-
payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC)
reviews and Recovery Audit Contractor (RAC). As states reopen, and given the importance of
medical review activities to CMS’ program integrity efforts, CMS expects to discontinue
exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the
public health emergency. If selected for review, providers should discuss with their contractor
any COVID-19-related hardships they are experiencing that could affect audit response
timeliness. CMS notes that all reviews will be conducted in accordance with statutory and
regulatory provisions, as well as related billing and coding requirements. Waivers and
flexibilities in place at the time of the dates of service of any claims potentially selected for
review will also be applied.


Q. Is CMS enforcing signature requirements on proof of delivery slips in response to the
COVID-19 pandemic, for Dates of Service (DOS) within the PHE for the COVID- 19
pandemic?
A. Given the nature of the pandemic and the inability to collect signatures during this time, CMS
will not be enforcing the signature requirement. Typically, Part B drugs and certain Durable
Medical Equipment (DME) covered by Medicare require proof of delivery and/or a beneficiary’s
signature. Suppliers should document in the medical record the appropriate date of delivery and
that a signature was not able to be obtained because of COVID-19.


Q. For ambulance services that require a physician or certain non-physician personnel to
sign and certify that a non-emergency ambulance transport is medically necessary, are
these signature requirements not required during the COVID-19 PHE?
A. We understand that in certain situations during the COVID-19 PHE it may not be feasible to
obtain the practitioner signature. Therefore, for claims with dates of service during the COVID-
19 PHE (January 27, 2020, until expiration), CMS will not review for compliance with
appropriate signature requirements for non-emergency ambulance transports during medical
review, absent indication of fraud or abuse. Ambulance providers and suppliers should indicate
in the documentation that a signature was not able to be obtained because of the ongoing
COVID-19 pandemic. However, we note that Medicare Part B covers ambulance transport

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services only if they are furnished to a Medicare beneficiary whose medical condition is such
that other means of transportation are contraindicated, and the beneficiary’s condition must
require both the ambulance transportation itself and the level of service provided in order for the
billed service to be considered medically necessary.


Q. Is CMS pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport
(RSNAT) Prior Authorization Model?
A. Effective March 29, 2020, certain claims processing requirements for the Repetitive,
Scheduled Non-Emergent Ambulance Transport Prior Authorization Model were paused in the
model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina,
Pennsylvania, South Carolina, Virginia, and West Virginia because of the COVID-19 pandemic.
During the pause, claims for repetitive, scheduled non-emergent ambulance transports submitted
on or after March 29, 2020, were not stopped for pre-payment review if prior authorization had
not been requested by the fourth round trip in a 30-day period. During the pause, CMS (through
the MACs) continued to review any prior authorization requests that were submitted. Given the
importance of prior authorization activities to CMS’ program integrity efforts, CMS expects to
discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the
status of the public health emergency. CMS will resume full model operations and prepayment
review will resume for repetitive, scheduled non-emergent ambulance transport claims submitted
in the model states on or after August 3, 2020, if prior authorization has not been requested by
the fourth round trip in a 30-day period.
Following resumption of the model, the MAC will conduct postpayment review on claims that
were subject to the model that were submitted and paid during the pause. CMS will work with
affected providers to develop a schedule for postpayment reviews that not does significantly
increase provider burden. Claims that received a provisional affirmation prior authorization
review decision and were submitted with an affirmed Unique Tracking Number (UTN) will
continue to be excluded from most future medical review.


Q. The RSNAT model is currently scheduled to end on December 1, 2020. Given this pause,
will CMS extend the model beyond that date?
A. At this time, CMS is not planning an extension beyond December 1, 2020. If this did occur,
CMS would provide proper public notice.


Q. How does this pause in the RSNAT model affect a determination as to whether the
model meets the criteria to be expanded nationwide, as provided under section 1834(l)(16)
of the Social Security Act, and any next steps for expansion?
A. The pause in the model does not affect the efforts to expand the model nationwide as provided
under section 1843(l)(16). CMS continues its efforts to prepare for expansion.

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Q. How does this pause in the model affect evaluation of the RSNAT model?
A. The evaluation of the model will take into consideration the pause for the PHE for the
COVID-19 pandemic. Those claims will be reviewed through post payment review and will still
be factored into the evaluation.


Q. Is CMS pausing the Review Choice Demonstration for Home Health Services?
A. Effective March 29, 2020, certain claims processing for the Review Choice Demonstration
(RCD) for Home Health Services were paused in Illinois, Ohio, and Texas, because of the
COVID-19 pandemic. During the pause, home health claims submitted on or after March 29,
2020, were not be subject to the review choices made by home health agencies under the
demonstration. However, the MAC continued to review any pre-claim review requests that were
submitted.
Given the importance of prior authorization activities to CMS’ program integrity efforts, CMS
expects to discontinue exercising enforcement discretion beginning on August 3, 2020,
regardless of the status of the public health emergency. CMS will resume demonstration
operations in all states. The initial choice selection period will begin in North Carolina and
Florida on August 3, 2020 and end on August 17, 2020. The choice selection period for Ohio’s
second review cycle will also begin August 3, 2020 and end on August 17, 2020. Following
these choice selection periods, home health claims in all demonstration states (Illinois, Ohio,
Texas, North Carolina, and Florida) with billing periods beginning on or after August 31, 2020,
will be subject to review under the terms of the choice selected by the provider. This includes
pre-claim review, prepayment review, postpayment review, or any applicable 25% payment
reduction.
Following the resumption of the demonstration, the MAC will conduct postpayment review on
claims subject to the demonstration that were submitted and paid during the pause. CMS will
work with affected providers to develop a schedule for postpayment reviews that not does
significantly increase provider burden. Claims that received a provisional affirmative pre-claim
review decision and were submitted with an affirmed Unique Tracking Number (UTN) will
continue to be excluded from most future medical review.
CMS will provide additional details about the choice period on its demonstration website.


Q. The Home Health demonstration is currently scheduled to end on May 31, 2024. Given
this pause, will CMS extend the demonstration beyond that date?
A. At this time, CMS is not planning an extension beyond May 31, 2024. If this did occur, CMS
would provide proper public notice.




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Q. Is a signature required for all Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS) orders prior to submitting claims for payment during the COVID-19
PHE?
A. Yes, all DMEPOS orders require a signature prior to submitting claims for payment.
However, all DMEPOS, except Power Mobility Devices (PMDs), can be provided via a verbal
order. PMDs require a signed, written order prior to delivery. Practitioners should note that
orders can be signed electronically.


Q. When is CMS resuming the Prior Authorization Program for DMEPOS items?
A. Given the importance of medical review activities to CMS’ program integrity efforts, CMS
expects to discontinue exercising enforcement discretion beginning on August 3, 2020,
regardless of the status of the public health emergency. CMS will resume full operations for the
prior authorization program for certain DMEPOS items. For Power Mobility Devices and
Pressure Reducing Support Surfaces that require prior authorization as a condition of payment,
claims with an initial date of service on or after August 3, 2020, must be associated with an
affirmative prior authorization decision to be eligible for payment. For an updated list of items
that require prior authorization please visit: https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/DMEPOS/Downloads/DMEPOS_PA_Required-Prior-Authorization-List.pdf.


Q. When will CMS begin prior authorization for certain Lower Limb Prosthetics (LLP)?
A. Prior authorization will be required for certain LLPs (Healthcare Common Procedure Coding
System codes L5856, L5857, L5858, L5973, L5980, and L5987), with dates of service on or
after September 1, 2020, in California, Michigan, Pennsylvania, and Texas. On December 1,
2020, prior authorization for these codes will be required in all of the remaining states and
territories. Prior to the COVID-19 PHE, CMS had announced that prior authorization for the
specified LLPs would be required in the 4 states beginning May 11, 2020 and the remaining
states beginning October 8, 2020.


Q. When will CMS begin prior authorization for certain Hospital Outpatient Department
(HOPD) Services?
A. As finalized in the CY 2020 Outpatient Prospective Payment System final rule, prior
authorization for blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and
vein ablation began July 1, 2020.




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