CMS Announces Therapy Cap Exception Procedures

Exceptions Process:   CMS has established an exceptions process for the therapy caps that is effective retroactively to January 1, 2006.  Providers, whose claims have already been denied because of the caps, should contact their carrier to request that the claim be reopened and reviewed to determine if the beneficiary would have qualified for the exception.  In addition, providers who have not yet submitted claims for services on or after January 1, 2006 that qualify for the exception, should submit these claims for payment, and refund to the beneficiary any private payments collected because of the cap.

The exceptions process allows for two types of exceptions to caps for medically necessary services:  

§    Automatic Exceptions.   Automatic exceptions for certain conditions or complexities are allowed without a written request.  A request to the contractor for an exception is not required when services related to these conditions and complexities are appropriately provided and documented.  We anticipate that the majority of beneficiaries who require services in excess of the caps will qualify for automatic exceptions.

Manual Exceptions.   Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor responsible for processing the claims.  If the patient does not have a condition or complexity that allows automatic exception, but is believed to require medically necessary services exceeding the caps--the provider/supplier or beneficiary may fax a letter requesting up to 15 treatment days of service beyond the cap.  A treatment day is a day on which one or more services are provided.  The request must include certain documentation, including a justification for the request.  Contractors will make a decision on the number of treatment days they determine are medically necessary within 10 business days.  These requests for cap exceptions should be submitted prior to the date the cap is expected to be surpassed to avoid placing the beneficiary at risk of incurring the costs of treatment if the request is denied.

As with any new CMS claim process we will be working through the system to ensure that this is easy to use for both the patient and the practitioner. 

For more information regarding automatic and manual exceptions, please refer to the CMS fact sheet which can be found here: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782
 

To learn more on other injuries and conditions, link to Patient Education.