Which review choice should your California home health agency pick in 2026?
The short answer
In our read, most California agencies should pick pre-claim review (Choice 1) by December 16, 2026: you learn what a chart is missing before you bill, not months after you're paid. If you don't pick, CMS puts you in postpayment review on every claim. The dates still need the Office of Management and Budget (OMB) to approve CMS's paperwork.
You won't need new documents for this. The face-to-face note, the signed plan of care and the rest are already in a good chart. What you need is a pick by December 16, then a routine for getting each chart in front of Medicare's reviewer once reviews start on January 18.
What review choice changes
Medicare's rules for who qualifies for home health stay the same: the patient is homebound, under a practitioner's care, on a plan of care, needs skilled services, and had a face-to-face visit with a practitioner. Review choice changes when Medicare checks your proof. Its contractor checks the documentation on every traditional Medicare home health claim, either before you bill or after you're paid, and you pick which. Medicare Advantage claims aren't part of it.
It has run in Illinois since 2019, then Ohio, Texas, North Carolina, Florida and Oklahoma. MedPAC counted 2,914 Medicare-participating agencies in California in 2024, out of 12,234 nationwide, up from 1,533 in 2019.
The dates, and the OMB catch
- Selection opens: November 16, 2026
- Selection closes: December 16, 2026
- Reviews start: billing periods beginning on or after January 18, 2027
- Who's in: every California agency that bills Medicare's Jurisdiction 6 contractor, Wellpoint Federal
CMS says implementation depends on OMB approving its paperwork package (CMS-10599). CMS asked for emergency clearance in a Federal Register notice published November 2, and OMB logged the request November 5. As of November 6, OMB's site showed no decision. Either way, start with your charts.
You select in Wellpoint Federal's provider portal, once for each PTAN (your Medicare billing number). Wellpoint's instructions, posted November 5: log in, choose HHA RCD from the home page, open the tab labelled "Selection Period for LSOs" and follow the prompts.
Choice 1 versus Choice 2
| Choice 1: pre-claim review | Choice 2: postpayment review | |
|---|---|---|
| When it's checked | Before the final claim; you can start care first | After Medicare pays, by a records request (ADR) on every claim |
| The clock | An answer within 10 business days, resubmissions included | 45 days for you to send records, then 60 days for the contractor to decide |
| If it goes wrong | The letter lists what's missing; you fix it and resubmit | A denied claim's payment is taken back; normal appeal rights apply. Miss the 45 days and it's an overpayment |
| Your cash | Final claims wait for an approval and its tracking number (UTN) | Paid on your normal schedule |
| In California | One request per 30-day billing period, full episode documentation in each | Same as other states |
The California difference
Elsewhere, one pre-claim request can cover more than one 30-day billing period. Not in California. If you pick pre-claim review, plan on two requests per 60-day episode, each with the full packet.
Fine print
CMS's operational guide says "California HHAs must submit a separate pre claim review request for each 30-day billing period," and "all documentation for the episode must be submitted with each request, regardless of whether the request covers the first or second 30 days of the episode."
The 25% cut
In pre-claim review, a final claim that goes out without a decision on file is stopped for review before payment. If it's payable, Medicare still cuts it by 25%. You can't appeal that cut or bill the patient for it.
Earning lighter review
Every six months the contractor scores you: the share of pre-claim requests fully approved, or the share of claims approved in postpayment review. Partial approvals don't count.
At 90% or better on at least 10 requests or claims, you can pick one of three next steps:
- Choice 1: stay in pre-claim review.
- Choice 3, selective postpayment review: the contractor reviews a random sample of your claims every six months. Once you're in, you stay for the rest of the demonstration.
- Choice 4, spot check review: a random 5% of your claims are reviewed before payment, as long as you stay at 90%.
Below 90%, or under 10 requests or claims, you choose again between Choices 1 and 2. If you qualify and don't choose, you're put in Choice 3 for good.
Which one we'd pick
In our view, pre-claim review is the safer start for most agencies. A missing face-to-face note shows up in a letter before you bill, while you can still fix it and resubmit. Mary Carr of the National Alliance for Care at Home told Home Health Care News that once a submission is affirmed, "it’s pretty much guaranteed that you are going to get paid for that." It's also where most agencies landed: in fiscal 2024, 2,798 of the 4,374 agencies in the program were in pre-claim review, per CMS.
Postpayment review can fit an agency whose charts reliably pass review and that can't hold final claims while decisions come back. The trade: denials come out of money you've already spent. Katy Barnett of LeadingAge told the same publication that members in postpayment review say "it’s really hard to get to that 90% threshold."
In California the cost of pre-claim review is the extra request each episode. Carr said of the program in general that agencies "panic because it does take a lot to get started on this."
What the six states have reported
In fiscal 2024, 1,790,902 of 1,849,354 completed pre-claim requests were affirmed, or 97%. CMS's yearly report pools that across all six states, with no state breakdown, so it tells you little about any one agency.
Of claims appealed at the first level, 51.6% were overturned. CMS says the most common reason was documentation that wasn't sent the first time. Send the whole packet the first time.
Your plan for November 16 to January 18
The dates and counts in this plan are our suggestions; CMS sets only the selection window and the January 18 start.
- Before Nov 16: find your portal login. Confirm who can sign in to Wellpoint Federal's provider portal, and list every PTAN you bill under.
- Nov 16 to Nov 30: pull ten recent Medicare charts. Check each against CMS's five requirements, including a face-to-face visit related to the main reason for home health, within 90 days before or 30 days after the start of care.
- Same weeks: find where the gaps come from. If face-to-face notes or signed orders come in thin from referral sources, start those conversations now.
- By Dec 4: make the call, PTAN by PTAN. That leaves room before CMS's Dec 16 deadline.
- Nov 16 to Dec 16: select in the portal. Save the confirmation for each PTAN.
- If you chose pre-claim review, build the 30-day rhythm. Send each request well before the final claim, using the pre-claim checklist on Wellpoint's portal.
- Hold final claims that have no tracking number. That's how you avoid the 25% cut.
- From Jan 18: track your approval rate every week. Know your number before the contractor sends it.
Enzo makes home health software, and two of its tools fit this work. Enzo Intake checks a referral package for the face-to-face documentation when it arrives, and Enzo QA checks diagnosis codes, OASIS responses and Plan of Care alignment on each chart before submission, flagging what needs a second look. Your team makes the call.
Questions agencies are asking
What if OMB hasn't approved it by January 18?
CMS says implementation depends on that approval and hasn't said what happens to the dates if it comes late. Check CMS's review choice page before you build January's schedule.
A UPIC is reviewing us. Are we in?
CMS's operational guide says an agency under review by a Unified Program Integrity Contractor (UPIC) isn't eligible, but it still encourages every agency to make a selection.
A patient transfers to us mid-episode. Does the last agency's approval carry over?
No. An approval doesn't follow the patient to a new agency. You submit your own pre-claim request, with the full documentation.