The Review Choice Demonstration for Home Health Services (RCD) is a Medicare medical review program in six states: Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma. Each agency picks how its claims are reviewed, pre-claim review or postpayment review, and an agency that reaches a 90 percent affirmation rate earns lighter options. CMS extended it to May 31, 2029.
This page is for owners and billers in those states, or about to open a branch in one: who is in, the choices as CMS names them today, the threshold that moves an agency between them, and what each choice does to the timing of your money.
The sources are CMS's own: the RCD page (last modified September 25, 2026), the HH RCD Operational Guide ("Updated June 7, 2024"), the RCD FAQs ("Updated 6/7/2024") and the Federal Register. Palmetto GBA, which runs the reviews, has rebuilt its website, so its extension notice is quoted from an archived copy.
Which States Are In, and Since When
The Operational Guide: "The Review Choice Demonstration will be conducted in: Illinois, Ohio, North Carolina, Florida, Texas, and Oklahoma. It applies only to those HHAs located in the states who submit claims to the Palmetto GBA Medicare Administrative Contractor (MAC)."
| State | Applies to billing periods with a from date on or after |
|---|---|
| Illinois | June 1, 2019 |
| Ohio | September 30, 2019 |
| Texas | March 2, 2020 |
| North Carolina | September 1, 2021 ("Full implementation") |
| Florida | September 1, 2021 ("Full implementation") |
| Oklahoma | December 1, 2023 |
From the FAQs:
- The agency's PTAN decides it, not where the patient lives. "You are included in the demonstration if you bill using a Provider Transaction Access Number (PTAN) for a demonstration state," including for patients served across a state line. An agency in a non-demonstration state "would not be included."
- Traditional Medicare only. "The RCD demonstration only applies to Medicare beneficiaries covered under Fee-for-Service (FFS) Medicare."
- Every billing period. "As of April 1,2020, all billing periods are subjected to the Review Choice Demonstration regardless of the number of visits."
- The Notice of Admission is untouched. "Request for Anticipated Payments (RAPs) and Notices of Admission (NOAs) are not included in this demonstration."
Older articles that list Michigan and Massachusetts describe the predecessor. The 2016 Federal Register notice announced "a 3-year Medicare pre-claim review demonstration for home health services in the states of Illinois, Florida, Texas, Michigan, and Massachusetts." Neither of those two states is on the current list.
How Long It Runs, and Whether More States Are Coming
The FAQs date the start to June 1, 2019 and say "the demonstration end date is now May 31, 2029." The CMS page announced the extension on May 17, 2024, "for an additional 5 years," and Palmetto's notice that day says it "will continue in the current demonstration states of Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma."
On expansion, the CMS page says "CMS has the ability to expand the demonstration to additional states in the JM MAC jurisdiction if there is evidence of fraud, waste, or abuse in those states." The FAQs promise notice: "At least 60 days prior to the implementation date in your state, CMS will announce the date the demonstration will begin." As of the page's September 25, 2026 revision, no state has been added after Oklahoma.
Do not take the state list from the Federal Register. The RCD's entries there are paperwork notices, and the September 19, 2025 notice still reads "CMS has implemented the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas," without Oklahoma.
The Two Initial Choices
The CMS page says "HHAs will select from two initial choices," and names them:
- Pre-claim review. "A process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment." One request per 30-day billing period, though several periods can go on one request.
- Postpayment review. "Under this choice all claims submitted during the cycle will be pulled for postpayment review."
An agency that does not choose "will be automatically assigned to participate in Choice 2: Postpayment Review." The choice "is made at the Provider Transaction Access Number (PTAN) level," in Palmetto's eServices portal, by the account administrator.
The third initial option is gone: "CMS is removing Choice 3: Minimal Review with 25% Payment Reduction from the initial choice selections." The Operational Guide still has a chapter on it, with the note that after June 1, 2024 it "is no longer a review choice option in the demonstration."
The 90 Percent Threshold
The Operational Guide: "If the HHA's full affirmation rate or claim approval for those 6 months is 90% or greater (based on a minimum of 10 submitted pre-claim review requests or claims), the HHA may select one of the three subsequent review choices." Below that, "or they have not submitted at least 10 requests/claims, the HHA must again choose from one of the initial two options." The rate arrives "within 30 days of the end of the cycle."
What counts:
- "Only fully affirmed decisions will be factored into a HHA's affirmation rate."
- "The number of resubmissions is not counted against the affirmation rate." A second initial request is different: refiling under the right PTAN or with corrected dates leaves "both requests" in the rate.
- For spot check, "Partially paid claims do not count toward the 90% approval rate."
The CY 2026 final rule restates it: CMS uses "a 90 percent affirmation rate threshold in our Review Choice Demonstration for Home Health Services" (90 FR 55598).
The Subsequent Choices
| Choice, as the guide names it | What happens | How long it lasts |
|---|---|---|
| Choice 1: Pre-Claim Review | Pre-claim review continues for another 6 months | A cycle at a time. At or above 90%, stay or pick another subsequent choice |
| Choice 3: Selective Postpayment Review | "Every 6 months, the MAC will select for postpayment review a statistically valid random sample of claims" | The agency "will remain in this choice for the remainder of the demonstration" |
| Choice 4: Spot Check Review | A random 5% of claims, based on the previous 6 months' volume, go to prepayment review | While the agency keeps the 90% claim approval threshold. Below it, back to the initial two |
The default is the trap. An agency at 90 percent or better that misses the deadline "will automatically be assigned to participate in Choice 3: Selective Postpayment Review, and will remain here for the duration of the demonstration."
Warning
Choose by name, not by number. The Operational Guide says that after June 1, 2024 the remaining choices "are being renumbered," yet the guide, the June 2024 FAQs and the "Updated Review Choice Demonstration Flowchart" (a PDF file dated June 9, 2026) still call Selective Postpayment Review Choice 3 and Spot Check Choice 4. CMS's FY 2024 statistics, published September 16, 2025, use five numbers: Choice 3 is Minimal Reduction, Choice 4 is Selective Postpayment Review, Choice 5 is Spot Check Review. A biller who picks Choice 3 off the wrong document picks the one that never lets go.
What Each Choice Does to Cash Flow
| Choice | When the claim goes out | Where the risk sits |
|---|---|---|
| Pre-claim review | After the decision letter. The final claim must carry its unique tracking number (UTN) | A claim sent without a decision on file: prepayment review, then a 25% cut if payable |
| Postpayment review | On your normal schedule. "Each claim is processed and paid per CMS procedures" | Every claim gets an ADR afterward; no answer means an overpayment and recoupment |
| Selective postpayment | On your normal schedule | A random sample is reviewed after payment, for the rest of the demonstration |
| Spot check | On your normal schedule | Palmetto will "suspend 5% of claims over a 6-month period for prepayment review" |
Pre-claim review comes before the bill, not before the visit: "services can begin prior to the submission of the pre-claim review request and continue while the decision is being made." The decision on an initial request is due "within 10 business days (excluding federal holidays)." The final claim waits for it. The request needs a plan of care with "the physician's signature and date," plus the face-to-face documentation.
A claim billed under pre-claim review with no request on file is "stopped for prepayment review. If the claim is found payable, it will be subject to a 25% payment reduction." That reduction "is non-transferable to the beneficiary and is not subject to appeal."
Postpayment review pays first and asks later. Palmetto "will process for payment and send the HHA an additional documentation request (ADR)." The agency "will have 45 days to respond," and the MAC "will then have 60-days to review." Miss the ADR and "notice of an overpayment will be sent to the HHA and payment recoupment procedures will be initiated."
Practice, not rule: under pre-claim review the delay is your own paperwork, because a plan of care waiting on a signature is a final claim waiting to go out. Under postpayment review the money comes on time and a denial comes back later as an overpayment, which is harder on thin cash reserves.
For scale, CMS's FY 2024 statistics count 2,798 providers in pre-claim review and 849 in postpayment review. Program-wide, 97% of pre-claim review requests were affirmed, and prepayment and postpayment claim reviews had 84.4% approval. Those are program totals, not the cycle rate that moves an agency. How the 30-day period itself is paid is in how CMS pays home health and how much Medicare pays for home health.
Small Rules That Hold Up Claims
- Put each UTN on its own 30-day claim, "to avoid an RTP or ADR."
- A new start of care needs a new request: "a new PCR request will be required with a new SOC." A resumption of care in an affirmed period does not.
- Send the Notice of Admission first. Agencies in pre-claim review are encouraged "to submit the RAP/NOA prior to submitting a pre-claim review request."
- A non-affirmed request cannot be appealed. Resubmit it, or bill, take the denial and appeal that.
CMS calls pre-claim review "similar to prior authorization" (90 FR 55598). The difference that matters at intake, covered in referral to first visit, is that the visit does not wait for it.
Key Takeaways
- Six states: Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, for agencies there that bill Palmetto GBA, through May 31, 2029.
- Two initial choices remain, pre-claim review and postpayment review. Minimal Review was removed effective June 1, 2024.
- The bar is a 90% full affirmation or claim approval rate over six months, on at least 10 requests or claims.
- Missing the subsequent-choice deadline locks the agency into Selective Postpayment Review. Choose by name; CMS documents disagree on the numbers.
- Pre-claim review holds the claim until the decision. Postpayment review pays first and claws back later.
Frequently asked questions
Which states are in the Home Health Review Choice Demonstration?
Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma. It applies to home health agencies located in those states that bill Palmetto GBA, the Jurisdiction M Medicare Administrative Contractor. Michigan and Massachusetts were named in the 2016 pre-claim review notice but are not on the current list.
When does the Review Choice Demonstration end?
CMS extended it for five years effective June 1, 2024. The CMS FAQ document, updated June 7, 2024, puts the end date at May 31, 2029.
What affirmation rate does an agency need to leave 100 percent review?
A full affirmation rate or claim approval rate of 90 percent or greater for the six-month cycle, based on at least 10 pre-claim review requests or claims. Below 90 percent, or under 10 submissions, the agency chooses again between pre-claim review and postpayment review. Only full affirmations count.
Is Minimal Review with a 25 percent payment reduction still an option?
No. CMS removed Choice 3, Minimal Review with 25% Payment Reduction, from the initial choices as part of the extension effective June 1, 2024. The 25 percent reduction still exists in one place: a claim billed under pre-claim review without a pre-claim review decision on file, when prepayment review finds it payable.
What happens if an agency does not make a selection?
At the initial stage the agency is placed in Postpayment Review. An agency that qualifies for the subsequent choices and does not pick one is placed in Selective Postpayment Review and stays there for the rest of the demonstration.
Does pre-claim review mean care cannot start until Palmetto answers?
No. CMS says services can begin before the pre-claim review request is submitted and continue while the decision is being made. What waits is the final claim, which needs the unique tracking number from the decision letter.
Sources
- CMS, Review Choice Demonstration for Home Health Services: background, the 05/17/2024 extension update, the 09/01/2023 Oklahoma update. Page last modified 09/25/2026.
- CMS, HH RCD Operational Guide, "Updated June 7, 2024": chapters 2, 3, 5, 6, 11, 12, 13, 14 and 15.
- CMS, HH RCD FAQs, "Updated 6/7/2024": questions 2 to 6, 8, 10, 17, 22, 23, 31 to 33, 39, 51, 59, 61, 63, 67, 77, 83, 84, 86, 88, 98, 102 and 104.
- CMS, Updated Review Choice Demonstration Flowchart.
- CMS, Prior Authorization and Pre-Claim Review Program Stats for Fiscal Year 2024, September 16, 2025: the Home Health Services (HH RCD) page.
- Federal Register, CY 2026 Home Health PPS final rule, 90 FR 55598.
- Federal Register, Pre-Claim Review Demonstration for Home Health Services, June 10, 2016 (CMS-6069-N).
- Federal Register, Agency Information Collection Activities, September 19, 2025 (CMS-10599).
- Palmetto GBA, Home Health Review Choice Demonstration Extended Five More Years, published 05/17/2024 (archived copy).
- Related on this site: referral to first visit, how CMS pays home health, how much Medicare pays for home health.