The Review Choice Demonstration (RCD) is a CMS program that requires Medicare-certified home health agencies in six states to prove their claims are eligible for payment — either before the claim is paid or after — by choosing one of three review methods. Effective June 1, 2024, CMS extended the demonstration for an additional five years across Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma. For agencies in those states, the single most important decision is which review choice to make, because it determines whether your documentation is scrutinized up front (pre-claim review) or after payment (postpayment review) — and, ultimately, how predictable your cash flow will be.
This guide explains the three choices, the trade-off between pre-claim and postpayment review, the 90% affirmation threshold that unlocks lighter oversight, and exactly how agencies earn and keep a high affirmation rate. Every rule below traces to CMS or the Home Health Medicare Administrative Contractors so your team can verify it directly.
What the Review Choice Demonstration Is
RCD is a documentation-integrity demonstration, not a new payment model. It does not change what Medicare pays for a home health period — it changes when and how the Medicare Administrative Contractor (MAC) confirms the claim was justified. CMS's goal is to reduce improper payments in home health by verifying that services meet Medicare coverage and documentation requirements. The program is described in full on the CMS Review Choice Demonstration for Home Health Services page, and operational detail lives in the CMS RCD Operational Guide.
Every affected agency must actively make a selection during each choice-selection period. Failing to choose is not neutral — agencies that do not select a choice are defaulted into the most restrictive option.
The Three Initial Choices
When an agency first enters RCD (or after a performance cycle), it selects from three initial review choices.
Choice 1: Pre-Claim Review
Under pre-claim review (PCR), the agency submits documentation before the final claim, and the MAC issues a provisional affirmation (or non-affirmation) decision. An affirmed request means the claim, when submitted, will not be denied on the documentation grounds already reviewed. This front-loads the work but removes almost all payment uncertainty: you learn your claim is defensible before you bill it, and affirmed claims pay on a normal timeline. Pre-claim review is the choice most agencies with strong documentation prefer, because it converts audit risk into a predictable up-front task.
Choice 2: Postpayment Review
Under postpayment review, claims are paid first and reviewed afterward. The agency submits Additional Documentation Requests (ADRs) after payment, and the MAC decides whether the payment was justified — recouping funds when documentation does not support the claim. This defers the documentation burden but keeps every reviewed claim at risk of recoupment months after the cash has been spent, which makes financial planning harder for agencies with any documentation weakness.
Choice 3: Minimal Review With a 25% Payment Reduction
The third initial option is minimal review, in which claims undergo a limited postpayment spot check — but the agency accepts a 25% payment reduction on every affected claim, and that reduction cannot be appealed. In practice this is rarely chosen except by agencies that cannot commit to the documentation cadence of pre-claim or full postpayment review, because giving up a quarter of Medicare revenue is a steep price to avoid review.
Pre-Claim vs Postpayment: How to Choose
For most agencies the real decision is between Choice 1 and Choice 2, and it comes down to documentation confidence and cash-flow tolerance.
- Choose pre-claim review if your face-to-face, homebound, and skilled-need documentation is consistently strong, or you are willing to build the workflow to make it so. You do more work up front, but you know a claim is affirmed before you bill it — no surprise recoupments, and predictable payment timing.
- Choose postpayment review if you have short-term cash-flow pressure that makes waiting for pre-claim decisions painful — accepting that every paid claim carries recoupment risk until it clears review. This is the higher-variance path and it rewards agencies that are confident their charts will hold up after the fact.
The through-line is documentation quality. Pre-claim review turns a strong chart into fast, certain payment; a weak chart produces non-affirmations either way — you just find out sooner under pre-claim and later (after the money is gone) under postpayment. That is why the highest-performing RCD agencies treat pre-claim review not as a burden but as an early-warning system that catches a coverage gap while it can still be fixed. A disciplined home health review of each pre-claim packet is what makes that system work.
The 90% Affirmation Threshold and What It Unlocks
RCD rewards agencies that prove they can document correctly. Every six months, the MAC calculates the agency's pre-claim review affirmation rate (or postpayment approval rate), based on a minimum of 10 requests or claims. An agency that reaches a 90% or greater full-provisional-affirmation rate becomes eligible to move to a lighter-touch option for the next cycle — such as selective postpayment review or a spot-check review — dramatically reducing the volume of documentation the MAC examines.
This is the core incentive of the program: hit 90%, and you earn a lighter review burden; fall short, and you stay in full review. It reframes RCD from a compliance tax into a measurable target your operations team can manage toward — and it is why affirmation rate is the single metric to watch if you operate in an RCD state.
Which States, and Who Runs It
RCD currently applies in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma. It is administered through the Home Health & Hospice Medicare Administrative Contractors — Palmetto GBA and CGS — which process the pre-claim and postpayment reviews and coordinate choice selection. Palmetto GBA publishes state-facing RCD guidance and affirmation resources on its Jurisdiction M Home Health RCD pages, and the MAC proactively contacts affected providers ahead of each new selection window.
If you operate in more than one of these states, note that your affirmation performance and choice selection are tracked per the MAC's rules — so a single national documentation standard across your branches is the simplest way to keep every location above the 90% line.
How to Earn — and Keep — a High Affirmation Rate
Affirmation is won or lost on three documentation elements Medicare examines closely for home health:
- A compliant face-to-face encounter tied to the primary reason for home health, performed and documented within the required window by an allowed provider.
- Individualized homebound documentation — not a template phrase, but a patient-specific description of why leaving home requires a considerable and taxing effort.
- Clear evidence of skilled need — documentation that the services required the skills of a nurse or therapist, written to the individual patient.
Agencies that standardize these three elements — with a pre-submission checklist, a physician-query process for gaps, and tracking so no pre-claim request or ADR misses its deadline — routinely sustain affirmation rates in the 90s. Those that assemble packets ad hoc do not. Because a non-affirmation is a documentation failure rather than a clinical one, it is almost always preventable with the right workflow. That is precisely where a structured clinical documentation review and a well-run revenue cycle protect the revenue RCD puts at risk.
Frequently Asked Questions
Which states are in the Review Choice Demonstration?
As of the June 1, 2024 five-year extension, RCD applies to home health agencies in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma. The demonstration is administered by the Home Health & Hospice Medicare Administrative Contractors (Palmetto GBA and CGS).
What is the difference between pre-claim and postpayment review?
Under pre-claim review, the agency submits documentation before billing and receives a provisional affirmation, so the claim's coverage is confirmed before payment. Under postpayment review, claims are paid first and documentation is reviewed afterward, leaving each paid claim subject to recoupment if the record does not support it. Pre-claim review front-loads the work but removes payment uncertainty; postpayment review defers the work but carries recoupment risk.
What affirmation rate does an agency need under RCD?
An agency needs a 90% or greater full provisional affirmation rate (for pre-claim review) or approval rate (for postpayment review), calculated every six months on a minimum of 10 requests or claims. Reaching 90% makes the agency eligible to move to a reduced-review option, such as selective postpayment or spot-check review, for the next cycle.
What happens if an agency does not choose a review option?
Agencies that do not make an active selection during the choice-selection period are defaulted into the most restrictive option rather than left unreviewed. Every affected agency should select deliberately during each window, which the MAC announces in advance.
Medeoan helps home health agencies in RCD states build the documentation discipline that keeps affirmation rates high — standardized face-to-face, homebound, and skilled-need evidence, deadline tracking, and physician queries that close gaps before a packet goes out. If RCD is putting your revenue at risk, our home health review team can help you protect it.