The Review Choice Demonstration for Home Health Services (RCD) changes how Medicare checks your claims. It doesn’t change what Medicare covers. If your agency bills Medicare in an RCD state, you choose how your claims are reviewed, and that choice affects cash flow, staffing, and documentation work for as long as the demonstration runs.
This guide explains what RCD is, which states are in it, how each review choice works, how pre-claim review and ADRs run day to day, and how to get your agency ready.
California agencies: CMS plans to add California to RCD. For the selection window, start date, and California-only rules, read our guide: Home Health Review Choice Demonstration (RCD): What California Agencies Need to Know.
Latest update (as of November 8, 2026, America/Chicago) – On November 2, 2026, CMS announced it will implement RCD in California (Jurisdiction 6, Wellpoint Federal) for billing periods beginning on or after January 18, 2027, with a selection window of November 16 to December 16, 2026. (CMS RCD page; 91 FR 68960) – On November 6, 2026, OMB approved the emergency revision of PRA package CMS-10599 (OMB 0938-1311) without change (ICR 202611-0938-005). CMS’s Nov 2 page update still shows the older “dependent on approval” sentence and has not yet been refreshed. – A November 4, 2026 correction confirmed that the old “Minimal Review with 25% Payment Reduction” option is no longer part of RCD. (2026-22494) – The current five-year extension of RCD began June 1, 2024.
What is the Review Choice Demonstration, and why does CMS run it?
RCD is a Medicare fee-for-service demonstration that has home health agencies (HHAs) show they follow Medicare home health coverage rules through a review process they pick. CMS runs it under Section 402(a)(1)(J) of the Social Security Amendments of 1967, which lets the Secretary test better ways to investigate and prevent fraud.
CMS says the goals are to cut improper payments and Medicare appeals and to improve provider compliance. CMS also says RCD “should not delay care to Medicare beneficiaries, and does not alter the Medicare home health benefit.” The coverage rules stay the same. What changes is how and when your documentation gets checked.
Which states are in RCD?
| State | MAC | Status |
|---|---|---|
| Illinois | Palmetto GBA (Jurisdiction M) | Active |
| Ohio | Palmetto GBA (Jurisdiction M) | Active |
| Texas | Palmetto GBA (Jurisdiction M) | Active |
| North Carolina | Palmetto GBA (Jurisdiction M) | Active |
| Florida | Palmetto GBA (Jurisdiction M) | Active |
| Oklahoma | Palmetto GBA (Jurisdiction M) | Active |
| California | Wellpoint Federal (Jurisdiction 6) | OMB approved Nov 6, 2026; selection Nov 16–Dec 16 |
RCD applies based on where your agency is located and which MAC it bills. Always check the CMS RCD page for the current list.
The review choices
Each agency starts by picking one of two initial choices. The choice is made for each PTAN, so an organization with several provider numbers picks for each one. An agency that doesn’t choose is automatically assigned to Choice 2: Postpayment Review.
| Choice | How it works | Who can choose it |
|---|---|---|
| 1: Pre-Claim Review | You submit documentation before the final claim. The MAC decides within 10 business days, and affirmed claims carry a Unique Tracking Number (UTN). | Anyone, at the start or later |
| 2: Postpayment Review | Claims are paid, then reviewed. You get an Additional Documentation Request (ADR) and have 45 days to respond. | Anyone. This is the default if you don’t choose. |
| 3: Selective Postpayment Review | Every six months, the MAC reviews a statistically valid random sample of claims. Once you pick it, you stay in it for the rest of the demonstration. | Only agencies at 90% or higher |
| 4: Spot Check Review | The MAC pulls a random 5% of claims for prepayment review. You have to stay at 90% or higher to remain in it. | Only agencies at 90% or higher |
The 90% rule. Every six months, the MAC calculates each agency’s pre-claim affirmation rate or postpayment claim approval rate. An agency at 90% or higher on at least 10 requests or claims can choose Choice 1, 3, or 4. An agency that qualifies but doesn’t choose is placed in Choice 3. Agencies below 90%, or with fewer than 10 requests or claims, choose again between Choices 1 and 2.
What happened to the 25% option? Early versions of RCD offered “Minimal Review with 25% Payment Reduction.” CMS removed it in 2024, and the November 2026 correction confirmed it is no longer part of the demonstration. If you read older articles that list five choices, that is why.
How pre-claim review works
- Admit and document. Complete the OASIS, plan of care, face-to-face encounter, and certification as usual.
- Submit the request to your MAC through its portal, esMD, fax, or mail, with all required documentation, before you submit the final claim.
- Get a decision within 10 business days (federal holidays excluded), for both first requests and resubmissions.
- Track the UTN. Every decision gets a Unique Tracking Number. Affirmed claims must carry the UTN when billed.
- Resubmit if needed. A non-affirmed request can be resubmitted as many times as needed before the final claim. Mark it as a resubmission and include the original UTN.
- Bill the final claim with the UTN.
What the documentation must show. The request needs to support that the patient is homebound, is under a physician’s care with a plan of care that is set up and reviewed periodically, needs skilled services, and had a qualifying face-to-face encounter no more than 90 days before or 30 days after the start of care.
Rejection is not non-affirmation. The MAC rejects an incomplete or invalid request without medical review. Common reasons include sending it to the wrong MAC, a beneficiary with Medicare Advantage, invalid beneficiary or provider identifiers, missing clinical documentation, or another HHA already holding a UTN for the episode. A non-affirmation means the MAC reviewed the record and found coverage requirements weren’t met. The decision letter lists every reason.
Don’t bill without a decision. If an agency in pre-claim review submits a final claim without a pre-claim decision, the claim is stopped for prepayment review. If it is found payable, it is paid 25% less. That reduction can’t be appealed and can’t be passed on to the beneficiary.
Postpayment review and ADR basics
Under Choice 2, claims are paid first and reviewed afterward. Under Choices 3 and 4, a sample of claims is reviewed. Either way, the MAC sends an ADR asking for the record that supports the claim.
- You have 45 days to respond to an ADR. Missing the deadline usually means the claim is denied.
- Send the complete record: OASIS, plan of care and orders, face-to-face documentation, certification, and visit notes for the billing period.
- Overpayments found on paid claims are recouped, so a weak ADR response can take back money you already counted.
- Postpayment denials can be appealed through the normal Medicare appeals process.
Tips to get ready
- List every PTAN and decide which choice fits each one. Don’t let the default decide for you.
- Assign ownership for submissions, UTN tracking, resubmissions, and ADR deadlines.
- Audit charts for homebound language, face-to-face timing and content, signed orders, and plan of care.
- Write an RCD SOP that covers intake, packet assembly, submission, tracking, and follow-up.
- Hold final claims until a UTN with a decision is on file.
- Track your affirmation rate each cycle toward the 90% threshold.
- Brief referring physicians on what they need to document. CMS publishes a physician/practitioner letter.
- Model cash flow for claims that are held, delayed, or reviewed.
How HealthRev Partners helps
HealthRev Partners works with home health and hospice agencies on coding, OASIS review, and revenue cycle management. For RCD, we help with:
- RCD SOPs and workflows built around your EMR, intake process, and staff.
- Pre-claim review submission, including packet assembly, completeness checks, UTN tracking, and resubmissions.
- ADR support for agencies in postpayment review or with claims pulled for review.
- Coding and OASIS accuracy, so diagnoses, functional scoring, and the plan of care tell the same story.
RCD works best when the same team runs pre-claim review and billing. When HealthRev handles your RCM, pre-claim review, UTN tracking and final billing follow one coordinated workflow designed to reduce missed steps and avoidable delays.
Getting ready in California? See what California agencies need to know about RCD.
FAQ
What is the Home Health Review Choice Demonstration? It’s a Medicare demonstration in which home health agencies in certain states choose how their claims are reviewed for compliance with existing coverage rules. It doesn’t change the home health benefit.
Which states are in RCD? Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma are active, all under Palmetto GBA. California (Wellpoint Federal) was cleared by OMB on November 6, 2026; CMS lists selection November 16 to December 16, 2026, and a start for billing periods beginning on or after January 18, 2027.
What happens if an agency doesn’t pick a review choice? It’s automatically assigned to Choice 2: Postpayment Review.
Can an agency still choose a 25% payment reduction instead of reviews? No. That option was removed. A 25% reduction still applies if an agency in pre-claim review bills a claim without a pre-claim decision and the claim is found payable.
How do agencies qualify for lighter reviews? They need a 90% or higher affirmation or claim approval rate on at least 10 requests or claims in a six-month cycle. That opens Selective Postpayment Review and Spot Check Review.
How long does the MAC take on a pre-claim review request? The MAC decides within 10 business days, excluding federal holidays, for both first requests and resubmissions.
Talk to a specialist
If you want help choosing a review option, building SOPs, or running pre-claim review alongside billing, speak with a HealthRev Partners specialist.
This article is general information, not legal advice. See the Latest update box for date-specific details.
