Review Choice Demonstration for Home Health Services

Prior Authorization and Pre-Claim Review Initiatives

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Review Choice Demonstration for Home Health Services

Background

The Review Choice Demonstration for Home Health Services (RCD) provides flexibility and choice for Home Health Agencies (HHAs), as well as risk-based changes to reduce burden on providers demonstrating compliance with Medicare home health policies. HHAs will select from three initial choices:

  • Pre-claim review
  • Postpayment review
  • Minimal postpayment review with a 25% payment reduction

After a 6-month period, HHAs demonstrating compliance with Medicare rules through pre-claim review or postpayment review will have additional choices, including relief from most reviews except for a review of a small sample of claims. (To be eligible, HHAs must meet a 90% target full provisional affirmation rate based on a minimum 10 requests/claims submitted.)

This program reduces the number of Medicare appeals, improves provider compliance with Medicare program requirements, should not delay care to Medicare beneficiaries, and does not alter the Medicare home health benefit.

Timeline & Updates

Updates are provided in reverse chronological order; scroll down for earlier updates.

Update 03/02/2022:

Beginning April 1, 2022, CMS will implement the 25% payment reduction in North Carolina and Florida where applicable. Initially, to help NC and FL providers transition to full implementation in the demonstration, CMS had not implemented the 25% payment reduction. Following implementation, claims submitted on or after April 1, 2022 by providers in NC and FL that have selected Choice 1 and do not have a pre-claim review decision, or who selected Choice 3, will be subject to the 25% payment reduction.

Update 07/16/2021:

Full implementation of the Home Health (HH) Review Choice Demonstration (RCD) will begin effective September 1, 2021, for HH providers in North Carolina (NC) and Florida (FL). CMS will discontinue exercising the phased-in participation for HH RCD providers in these states. In preparation for full implementation, there will be an additional mid-cycle selection period, as detailed below:

  • Selection Period Start Date: August 1, 2021
  • Selection Period End Date: August 15, 2021
  • New Selection Effective Date: September 1, 2021

Providers who made a selection during the first selection period for Cycle 2 in April and wish to remain in the same option they previously selected do not need to take any action.

Providers who previously made a selection for Cycle 2 in April and wish to change their selection will have the ability to do so during the mid-cycle selection period. The RCD Choices available to these providers will be based on their Cycle 1 results.

Providers who did not previously make a selection for Cycle 2 and do not make a selection during this mid-cycle selection period will default to either Choice 2 (Postpayment Review) or Choice 4 (Selective Postpayment Review) based on their Cycle 1 results.

Cycle 2 for NC and FL will end on October 31, 2021.

In addition, we will resume applying the 25% payment reduction where applicable in all five demonstration states - Illinois, Ohio, Texas, Florida, and North Carolina.

CMS will continue to post updated information on this website. Please send any questions to: homehealthRCD@cms.hhs.gov.

Update 06/30/2021

CMS will be extending the phased-in participation of the Review Choice Demonstration for Home Health Agencies in Florida and North Carolina until 7/31/21.

  • Providers may continue submitting pre-claim review requests.
  • Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review.
  • Claims submitted without going through the pre-claim review process will process as normal and will not be subject to a 25% payment reduction. These claims may be subject to postpayment review in the future through the normal medical review process.

Update 03/26/2021

Due to the continuing public health emergency, CMS will continue the phased-in participation of the Review Choice Demonstration for Home Health Agencies in Florida and North Carolina for an additional 90 days. Providers interested in participating should make their Cycle 2 Choice selections between April 1, 2021 and April 15, 2021. Cycle 2 will begin on May 1, 2021 for those providers.

  • Providers may choose from a subsequent choice selection based upon their Cycle 1 results.
  • Providers that do not make a choice selection may continue submitting pre-claim review requests.
  • Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review.
  • Claims submitted without going through the pre-claim review process will process as normal and will not be subject to a 25% payment reduction. These claims may be subject to postpayment review in the future through the normal medical review process.
  • Providers do not need to take any further action if they choose not to participate.

Extension of Phased-in Participation: 12/22/2020

Due to the continuing public health emergency, CMS will be extending the phased-in participation of the Review Choice Demonstration for Home Health Agencies in Florida and North Carolina until 3/31/21.

  • Providers may continue submitting pre-claim review requests.
  • Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review.
  • Claims submitted without pre-claim review will process as normal without being subject to a 25% payment reduction. These claims may be subject to postpayment review in the future through the normal medical review process.

Providers do not need to take any further action if they choose not to participate.

Update 10/29/2020:

Due to the continuing public health emergency, CMS will be extending the phased-in participation in the RCD for HHAs in Florida and North Carolina until 1/1/21.

  • Providers in Choice I Pre-Claim Review can continue to submit pre-claim review requests.
  • Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review.
  • Claims submitted without pre-claim review will process as normal without being subject to a 25% payment reduction. These claims may be subject to postpayment review in the future through the standard medical review process.
  • Providers won’t need to take any further action if they choose not to participate in the demonstration.

Update 08/21/2020:

CMS is phasing in participation in the RCD for HHAs in North Carolina and Florida, for a limited period of time, to help ease the transition during the current public health emergency. Specifically, for HHAs in North Carolina and Florida:

  • Providers may submit pre-claim review requests for billing periods beginning 8/31/20.
    • Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review.
  • Claims submitted without going through the pre-claim review process will process as normal and will not be subject to a 25% payment reduction.
    • Claims may be subject to postpayment review in the future through the normal medical review process
  • Providers who have already made a choice selection do not need to take any further action if they choose not to participate.
  • CMS will reassess the phased-in approach in 60 days.

For Illinois, Ohio, and Texas:

  • Cycle 2 in Illinois and Cycle 1 in Texas will end on September 30, 2020. Affirmation and claim approval rates will be calculated based on review decisions made between February 1, 2020 and September 30, 2020 for Illinois providers and between March 2, 2020 and September 30, 2020 for Texas providers.
  • Cycle 2 in Ohio will begin on August 31, 2020, as previously noted.
  • Claims submitted under Choice 1 without going through the pre-claim review process will not be subject to a 25% payment reduction until further notice, but will be subject to prepayment review.

Resumption of Demonstration Activities Update: 07/07/2020

Given the importance of review activities to CMS’s program integrity efforts, CMS will discontinue exercising enforcement discretion for the RCD for Home Health Services beginning on August 3, 2020, regardless of the status of the public health emergency. The initial choice selection period will begin in North Carolina and Florida on August 3, 2020 and end on August 17, 2020. The choice selection period for Ohio’s second review cycle will also begin August 3, 2020 and end on August 17, 2020.

Following these choice selection periods, home health claims in all demonstration states (Illinois, Ohio, Texas, North Carolina, and Florida) with billing periods beginning on or after August 31, 2020 will be subject to review under the requirements of the choice selected. This includes pre-claim review, prepayment review, and postpayment review.

Following the resumption of the demonstration, MACs will conduct postpayment reviews on claims subject to the demonstration that were submitted and paid during the pause. CMS will post more information on the postpayment review process in the near future.

Please see Provider Burden Relief Frequently Asked Questions (PDF) for more information.

Update 03/31/2020

On March 30, 2020, CMS announced a pause of certain claims processing requirements for the RCD for HHAs in Illinois, Ohio, and Texas until the Public Health Emergency for the COIVD-19 pandemic has ended. In addition, the demonstration will not begin in North Carolina and Florida on May 4, 2020 as previously scheduled. Refer to the Provider Burden Relief FAQs (PDF) for more information.

Modified Implementation of RCD based on stakeholder feedback: 5/29/2018

On April 1, 2017, CMS paused the Pre-Claim Review Demonstration for HHAs to consider a number of changes in response to stakeholder feedback. On May 29, 2018, CMS first announced our intention to implement the RCD for HHAs in Illinois, Ohio, Texas, Florida, and North Carolina through a Paperwork Reduction Act (PRA) notice and sought initial public comments. You can read the published responses and additional information on the demonstration design. CMS received PRA approval for the RCD for HHAs from the Office of Management and Budget (OMB).

Related Links

HHAs may visit the Palmetto GBA Provider Portal for information and instructions on the selection process.

Contact Us

For questions or to request additional information, please contact us via email at homehealthRCD@cms.hhs.gov.

Page Last Modified:
03/02/2022 09:55 AM