PCR: Pre-Claim Authorization

Service Scope & Methodology

Under Medicare pre-claim review, an agency's documentation is checked before the claim is billed. Four Pillars reviews the documentation against the applicable PCR requirements, prepares and submits the complete PCR packet through the Palmetto GBA portal, tracks every affirmative and non-affirmative determination, and supports rework and resubmission, so that claims reach the payer complete and on time.

Key Scope of Work & Clinical Deliverables

• 01

  Pre-Claim Review (PCR) Eligibility

  Comprehensive review of applicable Medicare PCR requirements, service eligibility, and HCPCS coding selection to ensure claims meet current Palmetto GBA review criteria.

• 02

  Clinical Documentation Compliance Review

  Detailed validation of all required documentation, including physician orders, Face-to-Face (F2F) encounter documentation, primary diagnosis support, visit frequency, and home health eligibility requirements.

• 03

  Review of Documentation

  OASIS SOC/ROC, Recertification assessments, Face-to-Face evaluation, Plan of Care (POC), therapy evaluations, nursing documentation, and supporting clinical records are reviewed to confirm compliance prior to submission.

• 04

  PCR Submission Management

  Preparation, organization, and electronic submission of complete PCR packets through the Palmetto GBA portal with attention to Medicare documentation standards and timeliness requirements.

• 05

  Affirmative & Non-Affirmative Response Monitoring

  Active tracking of PCR determinations, prompt communication of review outcomes, and identification of documentation gaps requiring correction or resubmission.

• 06

  PCR Rework & Resubmission Support

  Resolution of non-affirmative determinations through documentation review, deficiency correction, clinician coordination, and timely resubmission to maximize approval outcomes.

• 07

  NOA & Medicare Compliance Oversight

  Review of Notice of Admission (NOA) requirements and coordination of supporting documentation to help agencies maintain Medicare compliance and reduce payment delays.

• 08

  Ongoing PCR Status Follow-Up

  Continuous monitoring of submitted reviews, pending requests, and determination status to ensure timely resolution and uninterrupted reimbursement workflows.

Supported Electronic Health Records (EHRs)

Our teams work natively inside your agency's existing EHR environment using secure, direct-access credentials with zero disruption to field clinicians.

KanTimeAxxessDevero (MyUnity)CompassusEpicHCHB (Homecare Homebase)MatrixCareBrightree (by ResMed)MEDITECHNetsmartWellSky (Kinnser)HealthWyseAlora (Powered by LivTech)Allscripts (Veradigm)McKessonCerner