Form CMS-10765 Review Choice Demonstration for Inpatient Rehabilitation

OMB Control Number: NEW
Expiration Date: XX/XX/202X

Review Choice Demonstration for Inpatient Rehabilitation Facility
Services
Inpatient Rehabilitation Facilities (IRFs) will initially choose between two options:
• Pre-claim review for all IRF claims or
• Postpayment review of all IRF claims
An IRF that chooses the pre-claim review option must submit a pre-claim review request prior to
the submission of the final claim for payment. IRFs have an unlimited number of resubmissions
of the pre-claim review request prior to the final claim being submitted for payment.
Submitters should include, at a minimum, the following data elements in an IRF pre-claim
review request:
Beneficiary Information
• Beneficiary’s Name;
• Beneficiary’s Medicare Number (also known as HICN or MBI); and
• Beneficiary’s Date of Birth.
Physician/Practitioner Information
• Physician/Practitioner’s Name;
• Physician/Practitioner’s National Provider Identifier (NPI);
• Physician/Practitioner PTAN (optional); and
• Physician/Practitioner’s Address.
Inpatient Rehabilitation Facility Information
• IRF Name;
• CMS Certification Number;
• PTAN (optional); and
• IRF Address.
Submitter Information
• Contact Name; and
• Telephone Number.
Other Information
• Submission Date;
• Indicate if the request is an initial or resubmission review
• If resubmission, the UTN must be included.
Additional Required Documentation
Each beneficiary’s medical record at the IRF must contain the following documentation:
• Pre-admission screening
o A comprehensive evaluation:

Serves as the primary documentation of the patient’s status prior to
admission and documents the specific reasons that led the IRF clinical
staff to conclude that the IRF admission was reasonable and necessary.
o Must include:
 Prior level of function
 Expected level of improvement
 Expected length of time to achieve that level of improvement
 Risk for clinical complications (detailed description)
 Conditions/comorbidities that caused the need for rehabilitation and
why these require physician monitoring (detailed description)
 Combinations of treatments needed
 Anticipated discharge destination
o Licensed or certified clinicians conducting the preadmission screening must
write out the detailed reasoning/justification for the IRF admission.
Individualized overall plan of care
o The purpose of the overall plan of care is for the rehabilitation physician to
gather pertinent information that has been collected regarding the patient’s
medical and functional treatment needs and goals since the beginning of
admission and to synthesize this information into an overall plan of care that
will guide the patient’s treatment during the IRF stay.
o A non-physician practitioner can fulfill the IRF services and documentation
requirements currently required to be performed by the rehabilitation
physician in 42 CFR § 412.622(a)(3), (4), and (5). Therefore, of a nonphysician practitioner with the current definition of a rehabilitation physician
in that we expect the IRF to determine if the non-physician practitioner has
specialized training and experience in inpatient rehabilitation and may
perform any of the duties that are required to be performed by a rehabilitation
physician, provided that the duties are within the non-physician practitioner’s
scope of practice under applicable state law.
Resubmissions will require additional documentation, when available
o The overall plan of care:
 Additional information from the post-admission physician evaluation.
Information garnered from the assessments of all therapy disciplines
and other clinicians involved in treating the patient should be taken
into consideration as well.
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IRFs with claims undergoing prepayment or postpayment review should follow the normal
claim review processes.
PRA Disclosure:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-NEW. The time required to complete this information collection is estimated to average 0.5
hours or 30 minutes per response for States. This time includes preparing, reviewing and submitting required
documents. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C426-05, Baltimore, Maryland 21244-1850.