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 husband and I are both seniors with our share of physical difficulties. He had open heart surgery a few months ago, and I am oxygen dependent with severe arthritis. The home health aide who helps us is very conscientious. She assists him with daily tasks, prepares meals, and goes far beyond what we had hoped. Thank you for your professionalism and dedication.

December 19, 2016