What is Pre-Claim Review?

“Pre-claim review” means that our agency must submit key documentation as soon as possible after the start of each Medicare episode. These documents will be evaluated by CMS. If the documentation does not demonstrate each patient’s eligibility for service based on her/his need for skilled nursing and/or therapy services, as well as their continuing, documented homebound status, then the claim will be denied.

What Does Pre-Claim Review Mean for Our Referral Partners?

Diamond Home Care will be working closely with you and your office staff to collect the documents necessary for each pre-claim review. Time will be of the essence, and we intend to work with you to make the process as efficient as possible.


  1. Signed, dated Face-to-Face Certification that specifies the date on which the encounter occurred (must be within 90 days prior to the initial Start of Care or within the first 30 days following the Start of Care.) 
  1. Actual Progress Note, Discharge Summary, or other Encounter Record used by the certifying physician to justify eligibility. This encounter must be related to the reason for the patient’s home health skilled need and must establish the patient’s homebound status.
  1. Agency-generated Assessment Summary from our Patient Assessment (signed, dated, and incorporated into the certifying physician’s medical records).
  1. Signed, dated Plan of Care (POC).
  1. Signed, dated Therapy Evaluations that serve as supplemental orders for PT, OT, or SLP services.

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My dad has had three knee replacement surgeries in 15 years, and his recovery this time was by far the best experience! The PT and PTA assigned to help my dad were so caring yet firm. They taught him how the exercises he was doing would help him gain strength and mobility over the long term. I'm happy to report that he's still doing the exercises months later.

Marlene December 16, 2016