RCD Pre-Claim Review Guide (Publication Package)

Medicare RCD Pre-Claim Review for Home Health Agencies: A Complete Guide to Requirements, Documentation, and Approval

RCD pre-claim review is a Medicare process in which a home health agency (HHA) sends supporting documentation for a 30-day billing period to its Medicare Administrative Contractor (MAC) before submitting the final claim. The MAC returns a provisional affirmed or non-affirmed decision, generally within 10 business days, and the agency reports the decision’s Unique Tracking Number (UTN) on the claim. Pre-claim review is one of two initial choices under the Review Choice Demonstration (RCD), which applies today to agencies in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma, and is scheduled to begin in California for billing periods starting on or after January 18, 2027.

Last verified against CMS guidance on November 5, 2026. RCD details can change, so confirm current requirements with CMS and your MAC before acting on them.

What Is the Medicare Review Choice Demonstration (RCD)?

The Review Choice Demonstration for Home Health Services is a CMS program that lets agencies choose how they demonstrate compliance with Medicare home health requirements. According to the CMS RCD page, the demonstration is intended to reduce appeals, improve provider compliance, and avoid delaying care. It does not change the Medicare home health benefit itself.

CMS extended the demonstration for five years effective June 1, 2024, and removed the former option of minimal review with a 25% payment reduction.

Definition: Pre-claim review under RCD is a review of an agency’s supporting documentation for a 30-day billing period, completed before the final claim is submitted. The decision letter and UTN show whether the MAC provisionally affirmed or non-affirmed the request.

Current RCD Program Status and Participating States

The CMS RCD page (last modified November 4, 2026) and the updated RCD Operational Guide identify two MAC jurisdictions:

• Palmetto GBA (Jurisdiction M): Illinois (from June 1, 2019), Ohio (September 30, 2019), Texas (March 2, 2020), North Carolina and Florida (full implementation September 1, 2021), and Oklahoma (December 1, 2023).
• Wellpoint Federal (Jurisdiction 6): California. CMS announced that RCD will apply to billing periods beginning on or after January 18, 2027, with a choice selection period of November 16 to December 16, 2026. Implementation depends on approval of revisions to the demonstration’s Paperwork Reduction Act package (CMS-10599/OMB 0938-1311).

RCD applies to HHAs located in these states that bill the named MACs, and to Original Medicare fee-for-service beneficiaries. Requests for Medicare Advantage or Medicaid beneficiaries are rejected. HHAs under Unified Program Integrity Contractor (UPIC) review are not eligible to participate. CMS has previously stated that it can add states within the Jurisdiction M MAC when claims data support it, as it did with Oklahoma, so agencies outside the current states should keep watching CMS updates.

Review Choices Available to Home Health Agencies

Initial choices

Agencies start with one of two choices, selected at the PTAN level through the MAC’s provider portal no later than two weeks before the demonstration begins in their state:

• Choice 1: Pre-claim review. Submit documentation for each 30-day period before the final claim.
• Choice 2: Postpayment review. Submit claims as usual. The MAC reviews claims through Additional Documentation Requests (ADRs), and the agency has 45 days to respond.

Agencies that do not make a selection default to Choice 2.

Choices after the first six-month cycle

Performance is measured in six-month cycles. An agency with a full affirmation rate (pre-claim review) or claim approval rate (postpayment review) of at least 90%, based on at least 10 requests or claims, may then choose:

• Choice 1: Continue pre-claim review.
• Choice 3: Selective postpayment review. A random sample of claims is reviewed every six months, and the agency stays in this choice for the rest of the demonstration.
• Choice 4: Spot check review. A random 5% sample of claims is reviewed before payment.

Below 90%, or with fewer than 10 submissions, the agency returns to the two initial choices. Only fully affirmed decisions count toward a pre-claim review affirmation rate, and the MAC reports results within 30 days after each cycle ends.

How RCD Pre-Claim Review Works

1. Confirm your choice and PTAN. Selections are made per PTAN.
2. Submit the Notice of Admission as usual. NOAs are outside the demonstration, and CMS encourages agencies in pre-claim review to submit the NOA before the pre-claim review request.
3. Submit a request for each 30-day billing period before the final claim. Outside California, agencies can use the multiple billing period option, and each 30-day request receives its own UTN.
4. Receive the decision. The MAC notifies the agency and the beneficiary within 10 business days, excluding federal holidays, for both initial and resubmitted requests.
5. Bill with the UTN. The UTN must appear on the final claim whether the decision was affirmed or non-affirmed.

If a claim that should carry a UTN is submitted without pre-claim review, the MAC stops it for prepayment review and sends an ADR with a 45-day response window. If the claim is found payable, it is subject to a 25% payment reduction that cannot be passed to the beneficiary and is not appealable.

The demonstration covers final home health claims (type of bill 329), replacement and adjustment bill types, and the visit-level HCPCS G-codes listed in the Operational Guide.

RCD Pre-Claim Review Documentation Requirements

Required data elements

At a minimum, the Operational Guide calls for:

• Beneficiary: name, Medicare Beneficiary Identifier (MBI), date of birth
• Certifying physician or practitioner: name, NPI, address (PTAN optional)
• Agency: name, NPI, CMS Certification Number, PTAN, phone, address
• Submitter: contact name, email, telephone
• Request details: benefit period (initial or subsequent), submission date, from and through dates for the 30-day billing period and the 60-day episode, whether the request is initial or a resubmission, number of periods requested, and the state where services were rendered

Clinical documentation

The medical record must support that the patient is:

• Confined to the home. There is a normal inability to leave home, leaving requires considerable and taxing effort, and the patient either needs supportive devices, special transportation, or another person’s help to leave, or has a condition that makes leaving home medically contraindicated.
• Under the care of a physician.
• Receiving services under a plan of care established and periodically reviewed by a physician.
• In need of skilled services.
• Supported by a qualifying face-to-face encounter that occurred no more than 90 days before the start of care or within 30 days after it, relates to the primary reason for home health, was performed by an approved provider type, and is dated by the certifying physician.

Chapter 7 of the Medicare Benefit Policy Manual explains the underlying coverage criteria. When one request covers more than one period, a valid plan of care is required for each additional period. When 30-day periods are submitted separately, CMS directs agencies to include all documentation for the episode with each request. Agencies should also use the pre-claim review checklist on their MAC’s provider portal.

Submission Workflow

Agencies can submit through the MAC’s online portal, through esMD, by fax, or by mail. Responses return by the same method where available, and a fax response requires a return fax number. Palmetto GBA handles Jurisdiction M, and Wellpoint Federal handles California. In California, each request may include only one 30-day period because the multiple billing period option is not available.

A workable internal sequence looks like this: clinicians finalize the record, a quality reviewer checks the packet against the MAC checklist, the designated submitter sends the request, someone tracks the UTN and decision date, and billing applies the UTN to the claim. Naming one owner for each step prevents the gaps that cost agencies time.

Affirmation and Non-Affirmation

Provisional affirmation

A provisional affirmation is a preliminary finding that a future claim likely meets Medicare coverage, coding, and payment requirements. It is not a guarantee of payment. CMS notes that an affirmed claim can still be denied for technical requirements that can only be checked after the claim is processed, or because information was not available when the request was reviewed. Review contractors may audit affirmed claims when fraud or inappropriate utilization is suspected, and claims can be selected for the Comprehensive Error Rate Testing (CERT) sample. An affirmation also does not transfer if the beneficiary changes agencies.

Non-affirmation

The MAC’s decision letter lists the reasons for a non-affirmation. When documentation errors are the problem and the patient otherwise appears to meet coverage criteria, the MAC will call the agency to provide individualized education and encourage a prompt resubmission. A claim submitted with a non-affirmed UTN will be denied, and ordinary claim appeal rights then apply. RCD does not include a separate appeal for the non-affirmed pre-claim decision itself.

Rejection is different

A rejected request is one the MAC could not process because of incomplete or invalid information. It is not reviewed for medical necessity and is not counted as a non-affirmation.

Resubmitting a Pre-Claim Review Request

1. Read the entire decision letter and note every reason listed.
2. Correct the package and add the documentation the letter identifies.
3. Mark the request as a resubmission and enter the non-affirmed UTN.
4. Submit the complete package again. The MAC decides within 10 business days.

For a rejected request, fix the error, include all original documentation again, and mark the request as initial if it was initial. Ask your MAC how resubmissions are counted toward your cycle results so you can plan around the 90% threshold.

Common Errors That Delay or Derail Pre-Claim Review

Rejection triggers listed by CMS: a request sent to the wrong MAC; a beneficiary enrolled in Medicare Advantage or Medicaid; an invalid or missing MBI or beneficiary name; invalid or missing PTAN, NPI, or type of bill; no clinical documentation attached; and a UTN already held by another agency for the same episode.

Documentation gaps worth checking before you submit (drawn from the coverage criteria above, not from a statistic):

• A homebound narrative that names the diagnosis but never explains why leaving home takes considerable and taxing effort
• A face-to-face encounter outside the allowed window, unrelated to the primary reason for care, or missing the physician-documented date
• A plan of care that is incomplete, unsigned, or missing for an added period
• Visit notes that do not show the need for skilled services
• Visit notes and orders that do not align with the plan of care
• Dates or demographics that differ between the request form and the medical record