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Tags Posts tagged with "Novitas Solutions"

Novitas Solutions

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Novitas Solutions has released the Cycle 2 results for the inpatient rehabilitation facility (IRF) review choice demonstration (RCD). The Cycle 2 results letters were issued on September 10, 2025, and are available in Novitasphere.

IRFs will have a 2-week choice selection period for Cycle 3 from October 7, 2025 – October 20, 2025, using the Novitasphere portal.

Cycle 3 Choice Selection Options

If the approval rate meets or exceeds target affirmation rate of 85% for Cycle 2 (based on a minimum of 10 submitted pre-claim review requests or claims), the IRF may select 1 of the 3 subsequent review choices:

  • Choice 1: Pre-claim review (PCR)
  • Choice 3: Selective post-payment review (default if no review choice is made)
  • Choice 4: Spot check prepayment review

If the IRF’s affirmation or claim approval rate is less than the target affirmation rate or they have not submitted at least 10 requests/claims, the IRF must again choose from 1 of the initial 2 options:

  • Choice 1: Pre-claim review (PCR)
  • Choice 2: Post-payment review (default if no review choice is made)

Cycle Stats Reminder

IRFs can access information about their affirmation/approval rate at any given time during the current or previous review cycle through the Cycle Stats option in Novitasphere. Visit here for more information on cycle stats.

IRF RCD Questions

Questions or concerns regarding the IRF RCD should be directed to the IRF Customer Service line at 855-340-5975, Monday – Friday, 8:00 am – 6:00 pm.

IRF RCD Resources and Educational Opportunities

Visit the Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD) web page for important information about the IRF RCD and upcoming educational events, including a recording of the September 24, 2025, webinar on IRF RCD: Cycle 2 Results and Transitioning to Cycle 3.

Important Deadlines

  • October 7, 2025 – October 20, 2025, Cycle 3 Choice Selection
  • November 1, 2025 – April 30, 2026, Cycle 3 Review Dates
  • On or before May 30, 2026, Cycle 3 Affirmation/Approval Rate Communication

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Novitas Solutions, Medicare Administrative Contractor (MAC) for Pennsylvania, will conduct a webinar that will focus on the inpatient rehabilitation facility (IRF) coverage and documentation requirements. Representatives from Novitas will examine common errors identified by the Office of the Inspector General (OIG) Comprehensive Error Rate Testing (CERT) program, and recent medical review activities, and outline resources and best practices to improve compliance with Medicare program requirements for IRF services. The webinar will be held from 1:00 pm – 2:30 pm. Additional information, including registration, is available here.

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Photo by Tingey Injury Law Firm on Unsplash

Novitas Solutions has announced that there are changes to the Amount in Controversy (AIC) for appeals filed on or after January 1, 2025. The AIC requires the claims value in dispute to meet the threshold for obtaining an Administrative Law Judge (ALJ) hearing and a judicial review in federal district court. The AIC is recalculated and published on an annual basis and is identified in a provider’s appeal notice of decision.

The AIC for appeals filed on or after January 1, 2025:

  • ALJ hearing will increase to $190.
  • Federal district court will increase to $1900.

The amount in controversy is calculated in the following manner:

  • Amount Charged minus Medicare Payments Already Made or Awarded = Subtotal Balance
  • Subtotal Balance minus Any Applicable Deductible/Coinsurance = AIC

Novitas Solutions is the Medicare Administrative Contractor (MAC) for Jurisdiction JL, which includes DC, DE, MD, NJ, and PA.

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Novitas Solutions, the Medicare Administrative Contractor (MAC) for Pennsylvania, will be conducting a three-day Medicare Compliance Matters Virtual Symposium. The symposium is free of charge and will be conducted September 17 – September 19. It will offer 44 webinars that include essential information, updates, and key information on Medicare compliance.

Members who are Medicare-certified providers are encouraged to review the agenda and register for sessions that you would benefit from. The full agenda and registration information is available here.

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Novitas Solutions, Medicare Administrative Contractor (MAC) for Pennsylvania, continues to release inpatient rehabilitation facility review choice demonstration (IRF RCD) program updates, resources, upcoming educational opportunities, and important deadlines as IRFs in PA go through this implementation process.

Included in their most recent updates is:

  • Updated Frequently Asked Questions (FAQs)
  • An upcoming educational opportunity
    IRF RCD: Cycle 1 Progress — October 2, 2024, 1:00 pm – 2:30 pm
    Registration will be released soon and will be available here.

IRF RCD was initially implemented in Alabama in 2023, with the second round being implemented in Pennsylvania on June 17, 2024. The Centers for Medicare and Medicaid Services (CMS) created this process to ensure Medicare coverage and documentation requirements are likely met. This program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay medically necessary care to Medicare beneficiaries.

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On April 24, 2024, Novitas Solutions hosted their first webinar for inpatient rehabilitation facilities (IRF) in preparation for the start date of the IRF Review Choice Demonstration (RCD) in Pennsylvania on June 17, 2024. Novitas is the RCD contractor for the state of Pennsylvania. The webinar provided an overview of the process, the different review choices, and the instructions for contractor-specific portal (Novitasphere). While the webinar primarily covered the basics of the program as previously laid out in CMS’s materials, there was some new information that was shared:

  1. For the first time, Novitas introduced the clinical leadership team for the demonstration in Pennsylvania:
    • Ene Ojile, the Contract Medical Director overseeing the RCD in Pennsylvania. Dr. Ojile is Board-Certified in Physical Medicine & Rehabilitation (PM&R), and she most recently served as Medical Director for a large freestanding inpatient rehabilitation hospital.
    • Jessica Hicks, RN, MSN, the Medical Review Manager.
    • Mia Jackson, RN, BSN, the Medical Review Team.
  2. There was some discussion and confusion about the methodology Novitas will use to calculate individual hospital’s affirmation rates under the RCD. During the webinar, Novitas staff stated that the total number of submissions and resubmissions would be included in the calculation, potentially penalizing hospitals for completing resubmissions even if the claim is eventually affirmed. After the webinar, Novitas circulated a “clarification” indicating that, “The number of resubmissions is not counted against the affirmation rate.” Additional clarification will be requested to confirm how the rates will be calculated and that the same methodology will be used as in Alabama.

The slides from the April 24 webinar are now available, and Novitas has also posted a recording of the main presentation (without the public Q&A portion) available here.

Novitas will also be hosting the following training and education webinars leading up to the start date. You can register for these webinars at their website.

  • May 2 — Review Choice Selection & Process (PA IRF Providers Only)
  • May 3 — RCD: How to Prepare (All JH and JL IRF Providers)
  • June 4 — Pre-Claim and Post-Payment Review Submissions (PA IRF Providers Only)

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The next phase of the Centers for Medicare and Medicaid Services (CMS) inpatient rehabilitation facility (IRF) review choice demonstration (RCD) is scheduled to be implemented in Pennsylvania on June 17, 2024, and will last for five years. This demonstration applies to only IRF providers physically located in Pennsylvania.

Between May 3, 2024, and June 2, 2024, IRFs must select either 100% pre-claim review or 100% post-payment claim review.

CMS has stated that creating a review choice process will ensure Medicare coverage and documentation requirements are likely met. This program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay medically necessary care to Medicare beneficiaries.

Novitas Solutions is the Medicare Administrative Contractor (MAC) for Pennsylvania and will process the IRF claims. In preparation for the implementation of IRF RCD, Novitas Solutions will be conducting their first webinar on April 24, 2024, from 1:00 pm – 2:30 pm. Registration to participate in this webinar is now open. Members are strongly encouraged to participate in this webinar to prepare for this demonstration. If the registration link does not work, please copy and paste the below link into your browser to register:
https://fcso.webex.com/webappng/sites/fcso/meeting/register/0fd87e2111f7446fa477d0a25f78674c?ticket=4832534b000000073a942d9e6f94601b6b106adc8f502bcee359653432e8c326edb0f50ebc253329&timestamp=1711559626291&RGID=re6663754d2fe70defe3195e29c69465a

In addition to information on the CMS website, Novitas Solutions has a dedicated website that provides a great deal of information and resources on IRF RCD.

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