RCD (Review Choice Demonstration)

At the start of each cycle, an agency selects its review path. The initial options are pre-claim review, where the agency submits documentation to the review contractor before the final claim and receives a Unique Tracking Number (UTN) for affirmed requests, and postpayment review, where claims pay normally and records are reviewed afterward. A third initial option, minimal review with a 25 percent payment reduction, was removed from initial selections when CMS extended the demonstration in 2024. Agencies that demonstrate compliance, generally a 90 percent affirmation or claim approval rate over a review cycle, unlock lighter subsequent options, including selective postpayment review or spot-check review of a small sample of claims. Palmetto GBA administers the reviews across the demonstration states.

RCD began in Illinois in 2019 and rolled out to Ohio, Texas, North Carolina, and Florida, with Oklahoma added later. Effective June 1, 2024, CMS extended the demonstration for an additional five years across all six states: Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma. The extension signals that CMS views pre-claim review as an effective improper payment control for home health, and industry observers widely expect the model to influence future national policy. Agencies operating in demonstration states should treat RCD as a permanent operating condition, and multistate agencies should assume expansion is possible when planning documentation and staffing.

Pre-claim review front-loads the work but removes most payment risk: once a request is affirmed and the UTN is on the claim, the claim will not face additional medical review for those services, and payment is predictable. Non-affirmed requests can be corrected and resubmitted before billing, turning would-be denials into fixable paperwork. Postpayment review feels lighter day to day, but it leaves recoupment risk hanging over paid claims, and clawbacks arrive after the money has been spent. The tradeoff is administrative: pre-claim review demands that face-to-face documentation, orders, and the plan of care be complete and submitted early in every 30-day period, which strains agencies with slow physician signature turnaround.

High affirmation rates come from intake and documentation discipline, not billing heroics. Strong performers verify eligibility documentation at referral, chase face-to-face encounter notes and signed orders aggressively in the first days of the episode, and submit pre-claim requests early enough in each 30-day period to allow a resubmission if the first attempt is not affirmed. They track affirmation rates weekly, treat every non-affirmation as a root-cause exercise, and keep the 90 percent threshold in view because it earns the lighter review options in later cycles. The same documentation rigor pays off outside RCD too, since the eligibility elements reviewers check mirror what ADRs and TPE audits demand everywhere.