RCD Illinois Transition to Cycle 4

Published 07/16/2021

As the Review Choice Demonstration (RCD) for home health agencies (HHAs) in Illinois continues, the time for Cycle 4 is approaching.

If an HHA's full affirmation rate or claim approval rate is 90 percent or greater for the previous six-month period, it may choose one of the subsequent review options:

  • Choice 1: Start or continue participating in pre-claim review (PCR) for another cycle;
  • Choice 4: Selective postpayment review of a statistically valid random sample (SVRS) of claims every six months for the remainder of the demonstration; or
  • Choice 5: Spot Check Review of five percent of claims every six months to ensure continued compliance

Note: If an HHA is eligible for a subsequent review option, but does not make a selection during the selection period, the HHA will be placed in Choice 4.

If an HHA’s full affirmation rate or claim approval rate is less than 90 percent for the previous six-month period, it may choose one of the initial review options:

  • Choice 1: Start or continue participating in PCR for another cycle;
  • Choice 2: 100 percent postpayment review; or
  • Choice 3: Minimal post payment review with 25 percent payment reduction

Note: If an HHA is eligible for an initial review option, but does not make a selection during the selection period, the HHA will be placed in Choice 2.

For those options that are evaluated every six months, the claims or PCR requests reviewed during the cycle will determine the provider’s results. Providers will continue in their selected option during the calculation and selection period. The affirmation/claim approval rate calculation period occurs during the month of June 2021 with results letters being sent to HHAs by the end of June 2021. The selection period for Cycle 4 will take place from July 1, 2021, through July 18, 2021. HHAs that do not make a selection during that time period will default to either Choice 2 or Choice 4 as noted earlier in this article.

As providers transition from Cycle 3 to Cycle 4, please be advised of the actions required when changing from one choice to another.

If Your
Cycle 3
Choice was:

And Your Cycle 4 Choice is:

Here are the actions you will need to take:

Choice 1: PCR

Choice 1: PCR
  1. Continue PCR process. Data from June and July will be included in the Cycle 4 results.

Choice 1: PCR

Choice 2: Postpayment Review
  1. Continue to submit PCR requests through 7/31/2021. Data from June and July will be included in the Cycle 4 results.
  1. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed)
  2. Respond to ADRs as generated
  1. As of 8/1/2021, submit final claim for payment
  1. Final bill will adjust, and the ADR will generate
  2. Respond to ADR

Choice 1: PCR

Choice 3: Minimal Review
  1. Continue to submit PCR requests through 7/31/2021.
  1. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed)
  2. Respond to ADRs as generated
  1. As of 8/1/2021, submit final claim
  1. ADR will not generate
  2. 25 percent reduction will apply

Choice 1: PCR

Choice 4: Selective Postpayment Review
  1. Continue to submit PCR requests through 7/31/2021. Data from June and July will be included in the Cycle 4 results.
  1. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed)
  2. Respond to ADRs as generated
  1. As of 8/1/2021, submit final claim for payment
  1. Final bill will be adjusted, and the ADR will generate
  2. Respond to ADR

Choice 1: PCR

Choice 5: Spot Check
  1. Continue to submit PCR requests through 7/31/2021. Data from June and July will be included in the Cycle 4 results.
  1. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed.
  2. Respond to ADRs as generated
  1. As of 8/1/2021, submit final claim
  1. ADR will generate
  2. Respond to ADR

Choice 2: Postpayment Review

Choice 1: PCR
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results.
  2. Begin submitting PCR requests on 8/1/2021 for any claim that will be submitted on or after 8/1/2021 with a date of service on or after 6/1/2019
  1. Add UTN to claims for claims with PCR requests

Choice 2: Postpayment Review

Choice 2: Postpayment Review
  1. Continue to respond to ADRs

Choice 2: Postpayment Review

Choice 3: Minimal Review
  1. Continue to respond to ADRs sent for Choice
  2. As of 8/1/2021, submit final claim
  1. ADR will not generate
  2. 25 percent reduction will apply

Choice 2: Postpayment Review

Choice 4: Selective Postpayment Review
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results. 

Choice 2: Postpayment Review

Choice 5: Spot Check
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results. 

Choice 5: Spot Check

Choice 1: PCR
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results. 
  2. Begin submitting PCR requests on 8/1/2021 for any claim that will be submitted on or after 8/1/2021 with a date of service on or after 6/1/2019.
  1. Add UTN to claims for claims with PCR requests

Choice 5: Spot Check

Choice 2: Postpayment Review
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results. 

Choice 5: Spot Check

Choice 3: Minimal Review
  1. Continue to respond to ADRs sent for Choice 5.
  2. As of 8/1/2021, submit final claim
  1. ADR will not generate
  2. 25 percent reduction will apply

Choice 5: Spot Check

Choice 4: Selective Postpayment Review
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results. 

Choice 5: Spot Check

Choice 5: Spot Check
  1. Continue to respond to ADRs. Data from June and July will be included in the Cycle 4 results. 

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