Review Choice Demonstration in California: RCD Guide

The Review Choice Demonstration, or RCD, changes how Medicare reviews home health claims, not what Medicare covers. CMS plans to start it in California for 30-day billing periods beginning on or after January 18, 2027, and agencies choose how their claims will be reviewed during a window from November 16 to December 16, 2026. The details here are as CMS and Wellpoint Federal, the Medicare contractor for Jurisdiction 6, published them when we checked on November 12, 2026. They can change, so confirm them with CMS and Wellpoint Federal before you act. It is general education about Original Medicare, not legal advice, and it does not recommend a choice.

What is the Review Choice Demonstration?

RCD is a CMS demonstration that lets a home health agency choose how its claims are reviewed, with less review over time for agencies that show they follow Medicare rules (CMS Review Choice Demonstration page). It already runs in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, and CMS says California will follow the same processes.

CMS says RCD creates no new documentation requirements, and Wellpoint Federal says it changes the review process, not the home health benefit (CMS RCD FAQs, general question 13; Wellpoint Federal RCD overview). What changes is when the contractor looks at the records and what happens to the claim.

When does RCD start in California?

It applies to billing periods that begin on or after January 18, 2027, initial and recertification periods alike. A period that begins earlier is not included, even if its claim goes out later (CMS RCD FAQs, general questions 6 and 21).

One condition is worth watching. The CMS page says implementation "is dependent on approval of revisions to PRA package CMS-10599/OMB 0938-1311," the paperwork approval the Federal Register notice requested (a November 4 correction removed wording about an option no longer in that request). On November 12, 2026, the OMB record showed "Approved without change," concluded November 6, 2026 under emergency processing, expiring April 30, 2027. The same day, the CMS page, last modified November 6, still carried the "dependent on approval" sentence, and Wellpoint Federal's November 4 announcement still called the start "pending required approval." Watch both sites for an update.

Which agencies and claims are included?

All California agencies that bill Jurisdiction 6, whose contractor is Wellpoint Federal. Inclusion follows the Provider Transaction Access Number (PTAN) the agency bills under, so a branch billing under a California PTAN is included (CMS RCD FAQs, general question 5).

It covers final claims on bill types 327, 329, 32F, 32G, 32H, 32I, 32J, 32K, 32M, 32P and 32Q for the home health visit codes CMS lists, which can change (CMS RCD Operational Guide, chapter 3; Wellpoint Federal code list). These are outside it (CMS RCD FAQs, general questions 16 and 20):

• The notice of admission, which is sent as usual.
• Veterans Affairs claims, Part A to Part B rebilling, and condition code 20 and 21 bills.
• Medicare Advantage patients, because RCD applies only to Original Medicare.
• Claims where both the agency and the patient are part of an Accountable Care Organization.

An agency under Unified Program Integrity Contractor (UPIC) review does not take part while that review lasts, but should still make a selection (general question 18). CMS also says an agency will not be under Targeted Probe and Education (TPE) review and RCD at the same time (general question 25).

What are the review choices?

California agencies start with two choices. Two more open to agencies that meet the 90 percent threshold below (CMS RCD Operational Guide, chapters 2, 13 and 15).

Older materials may number these differently, because CMS removed a former initial option in 2024 (CMS update of May 17, 2024).

How and where is the selection made?

Only in the contractor's online portal, and only by the account administrator selected in that portal (CMS RCD FAQs, choice selection questions 2 and 4). Wellpoint Federal's steps are to log in to its Provider Portal, choose HHA RCD on the home page, open the "Selection Period for LSOs" tab and follow the prompts. The sample buttons on its instruction page do not send a choice (Wellpoint Federal, how to make a Review Choice Selection).

• The selection is made per PTAN and covers every National Provider Identifier (NPI) under it. An agency with several PTANs selects for each (choice selection question 8).
• A selection can be changed until the night the window closes (question 5).
• No selection means Choice 2, postpayment review (question 3).
• After a change of ownership, the new owner keeps the previous owner's selection (question 13).

What does a pre-claim review request need?

Under Choice 1, services can begin before the request and continue while it is reviewed, but the decision and its tracking number must come before the final claim. If a period ends first, the agency waits for the decision letter. CMS encourages sending the notice of admission first and letting it process (CMS RCD FAQs, general question 2 and Choice 1 questions 6, 7 and 9).

Three California rules stand out (CMS RCD Operational Guide, chapters 4 and 6):

1. Each request covers one 30-day period. Requesting several periods at once is not available in California.
2. All documentation for the episode goes with each request, whether it covers the first or second 30 days.
3. Only one agency may request review for a patient's period.

The request carries (chapter 6):

• Patient: name, Medicare Beneficiary Identifier and date of birth.
• Certifying physician or allowed practitioner: name, NPI and address.
• Agency: name, NPI, CMS Certification Number, PTAN, phone and address.
• Submitter: contact name, email and phone.
• Request details: initial or subsequent benefit period, submission date, the 30-day and 60-day dates, initial request or resubmission, number of periods, and the state where services are given.

The records must support the usual requirements: the patient is confined to the home, is under a physician's or allowed practitioner's care, has a plan of care, needs skilled services and had a face-to-face encounter related to the primary reason for home health (chapter 6). The plan of care must be signed and dated when sent, and later periods include the start-of-care encounter documentation (CMS RCD FAQs, Choice 1 questions 3 and 5). CMS does not expect the entire record, and there is no required form, though the contractor may offer checklists (Choice 1 question 2; general question 14). Wellpoint Federal lists the kinds of records a request may include on its documentation page.

Requests go through Wellpoint Federal's Provider Portal, CMS's electronic submission of medical documentation system (esMD), fax with Wellpoint Federal's coversheet, or mail (Wellpoint Federal, ways to submit requests). The decision comes back the same way (Choice 1 question 12).

What decisions can come back?

A decision goes to the agency and the patient within 10 business days, excluding federal holidays, for initial and resubmitted requests (CMS RCD Operational Guide, chapters 6 to 10 and 17).

• Provisional affirmation. A preliminary finding that the claim likely meets Medicare's coverage, coding and payment rules, for all or some requested services. The claim can still be denied for technical requirements or information not available at review, and it can still be audited if fraud or inappropriate use is suspected.
• Non-affirmation. The letter lists every reason. The agency can fix the problems and resubmit, marked as a resubmission with the non-affirmed tracking number, as often as needed before the final claim (CMS RCD FAQs, Choice 1 question 19). A non-affirmation cannot be appealed itself. A claim billed with that tracking number is denied, and the denial can be appealed.
• Rejection. Not a decision, and no medical review. Causes include the wrong contractor, a Medicare Advantage or Medicaid patient, invalid patient or provider details, no clinical documentation, or another agency already holding a valid tracking number. The agency corrects the error and sends it again with all original documents.

What is a UTN, and where does it go?

Every decision, affirmed or not, comes with a 14-byte unique tracking number (UTN), and each billing period gets its own. It must go on the final claim either way (CMS RCD Operational Guide, chapters 7 and 11). It goes in the treatment authorization field: form locator 63 on paper, and the loop 2300 REF segment with qualifier G1 electronically. CMS's guide and FAQ describe the character positions differently, so confirm the exact entry with Wellpoint Federal (CMS RCD FAQs, billing question 2).

• An adjustment keeps the UTN from the original claim (billing question 4).
• A valid UTN for a different period, put on the wrong claim, leads to an ADR (billing question 5).

CMS's materials do not settle what happens when a period was affirmed but its UTN is left off the claim. Asked about a wrong or missing UTN, the FAQ says the claim will "normally" be returned for correction if the UTN matches the claim's billing period (billing question 5). The guide says a claim sent without pre-claim review is stopped for prepayment review (chapter 12). Ask Wellpoint Federal which applies.

What happens to a claim sent without a pre-claim review?

Under Choice 1, a final claim for a period that never had a request is stopped for prepayment review. If payable, it is paid with a 25 percent reduction of the full claim amount. The reduction cannot be passed to the patient or appealed, though appeal rights on the claim itself remain (CMS RCD FAQs, Choice 1 question 23). The contractor sends an ADR, and the agency has 45 days to respond (CMS RCD Operational Guide, chapter 12).

What happens under postpayment review?

Under Choice 2, every claim sent during the cycle is pulled for review. The contractor processes it for payment, then sends an ADR for records such as the plan of care, agency records, progress notes and nursing visit notes (CMS RCD Operational Guide, chapter 13).

• The agency has 45 days to respond, and the contractor then has 60 days to decide.
• With no response, an overpayment notice follows and recoupment begins.
• Reviews use the same standards as without the demonstration, and denied claims keep their appeal rights.

How does the 90 percent threshold work?

Agencies are measured over six-month cycles, and results arrive within 30 days after a cycle ends (CMS RCD Operational Guide, chapters 14 and 15).

• 90 percent or more, on at least 10 requests or claims, opens Choices 1, 3 and 4.
• Below 90 percent, or fewer than 10, means choosing again between Choices 1 and 2.
• An agency that qualifies but does not select in time is placed in Choice 3 for the rest of the demonstration.
• Under Choice 1, only fully affirmed decisions count toward the rate.
• Results are figured per PTAN (FAQ choice selection question 8).

One point is not settled. The FAQ says resubmissions are not counted against the affirmation rate, but also that when a request under the wrong PTAN or with wrong dates is replaced by a new initial request, both count (CMS RCD FAQs, choice selection question 10, submission question 1 and Choice 1 question 29). How a non-affirmed request that is corrected and then affirmed counts is not spelled out. Ask Wellpoint Federal how it calculates your rate.

What should you ask your billing team?

1. Is every PTAN we bill under accounted for, and who is our portal administrator?
2. How will the UTN be carried onto each final claim and adjustment, and who checks it matches the claim's 30-day period?
3. Under pre-claim review, how will a final claim be held until its decision letter arrives?
4. How will ADRs be tracked against the 45-day deadline?
5. Have we asked Wellpoint Federal how a claim missing its UTN is handled, and how corrected non-affirmations count toward the 90 percent?

Related guides

See Medicare home health billing for periods, certification and deadlines, and why home health claims come back for returned, rejected and denied claims. The notice of admission guide covers the 5-day rule, and home health billing codes covers bill types and G-codes. For outside help, see choosing a home health billing company and new home health agency billing. For what LMNS covers, see home health billing services. The home health billing cheat sheet lists the certification and face-to-face deadlines on one page.

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