Review Choice Demonstration (RCD) Appeals for Home Health Services

As part of the appeal process under the demonstration for non-affirmative pre-claim review, pre-payment review or postpayment review submissions, all existing claims appeal rights remain unchanged under the demonstration. Claims that are denied under the demonstration are appealable. Non-affirmed, pre-claim review determinations are not appealable; however, providers have two options. 

Those options are resubmitting the pre-claim review request before filing a claim; or, submitting a claim, which will be denied, and then submitting an appeal. Please note that PCR affirmation and claim approval rates are based on your submissions during the active demonstration dates that had the decision rendered. Appeals data are not included in affirmation or claim approval rates.

If an HHA’s affirmation or claim approval rate is less than 90 percent, or they have not submitted at least ten requests/claims, the HHA must choose from one of the initial three options. Appeals data are not included in affirmation or claim approval rates.