Current News



Manual Medical Review Forms

Below you will find the various Medicare contractors and links to their respective Manual Medical Review and Advance Exception Request web page and applicable forms and documents. In addition, many of the sites inform providers of various systems to track the therapy cap.

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CMS Therapy Cap & Manual Medical Review Documents

Over the past several weeks, the Centers for Medicare & Medicare Services has released several transmittals, MedLearn Matters Article, a Fact Sheet and a Q&A document all pertaining to the therapy cap and manual medical review process. I have combined multiple news articles to include all the documents here.

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Manual Medical Review of Therapy Services

The Centers for Medicare & Medicaid Services (CMS) released transmittal 1117 on August 31, 2012 and was replaced by transmittal 1124 on September 24, 2012 that details what must be submitted when requesting an advance exception to the $3700 therapy cap threshold as well as guidelines the Medicare contractors must adhere to when an exception has been made by a provider. Transmittal 1124 can be accessed by clicking…

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Therapy Cap Update From CMS

On August 31, 2012, the Centers for Medicare & Medicaid (CMS) released transmittal 2537 that provides new and additional information regarding the 2012 therapy cap and the manual medical review process scheduled for implementation on October 1, 2012. Transmittal 2537 also provides information on where to place the certifying physician/NPP NPI number on the claim form for both private practices and non-private practices. In addition, CMS will be holding an open door forum on September 5, 2012 from 2:00PM – 3:30PM eastern time on the manual medical review of therapy claims. The call in number is 1-877-251-0301; Conference ID: 23782155.

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CMS Releases Therapy Provider Phase-In Information

On August 22, 2012, the Centers for Medicare & Medicaid Services released the therapy provider phase-in list for the manual medical review process implementation schedule. You can determine what phase you are in simply by looking for your NPI number within the phase-in list. If you do not locate your NPI number, it means you are in phase 3. You can also type in your NPI number in the box that states “Find in this Dataset” that is located in the upper right hand corner under “Create an Account”. Phase 1 providers will be subject to the manual medical review

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CMS Releases Transcript on Manual Medical Review Process Call

The Centers for Medicare & Medicaid Services issued the transcript on August 15, 2012 of the Open Door Forum call from August 7, 2012 on the manual medical review process scheduled for implementation on October 1, 2012. To access the transcript, click…

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Highmark To Require Prior Authorization for PT & OT Services

Highmark Inc., who serves 4.9 million members in Delaware, Pennsylvania, and West Virginia, announced on June 19, 2012 they will begin requiring prior authorization for physical therapy, occupational therapy, and manipulation services beginning September 1, 2012. In the press release, Highmark stated this program applies to Highmark members in insured groups in Pennsylvania and West Virginia. It also applies to Highmark individual members and Medicare Advantage members in those states. Groups that are self-insured may also participate. Members will not need to take any special steps as a result of this program. Providers will work directly with the vendor (Healthways)

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