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Illinois Pre-Claim Review Update

It has been roughly three months since the Centers for Medicare and Medicaid Services (CMS) launched the Pre-Claim Review Demonstration in Illinois, which was met with substantial push back from agencies as well as lawmakers. Concerns surrounding the demonstration led to an indefinite delay in its launch in additional states.

This week, CMS released additional data surrounding the affirmation of claims submitted for approval. The new data shows that in week 14 of the demonstration, 82% of pre-claim review requests in Illinois received provisional affirmation, either fully or partially affirmed. This is up from 66% during week 8 of the demonstration.

Agencies and industry groups alike have pushed back against the high affirmation rates, citing that partial affirmations still require agencies to resubmit their pre-claim requests creating additional administrative work. In addition there is concern whether the high affirmation rates is a result of Illinois being the only state currently participating in the demonstration. At this time, the implementation of the program in Florida, Texas, Massachusetts and Michigan has been paused.

CHAP will continue to monitor this issue and provide updates as they are made available. 

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