California Home Health RCD: Preparing for Pre-Claim Review and Postpayment Review Before the January 2027 Start

California home health agencies (HHAs) have a short runway. CMS has announced that the Review Choice Demonstration for Home Health Services (RCD) will apply to California billing periods beginning on or after January 18, 2027, with a selection period from November 16 through December 16, 2026. That leaves roughly ten weeks from today to choose a review option, build new workflows, train staff, and prepare certifying physicians and practitioners. CMS has noted that implementation depends on approval of revisions to the demonstration's information collection, so agencies should monitor CMS and Wellpoint Federal for any changes.

This article is a practical readiness guide. It focuses on the operational work needed to succeed under either initial review option: Choice 1, Pre-Claim Review, or Choice 2, Postpayment Review. It covers documentation audits, intake and certification workflows, pre-claim review packaging and submission, Unique Tracking Numbers (UTNs), ADR response under postpayment review, physician engagement, staffing, cash-flow planning, and a week-by-week timeline. It is educational and does not replace legal or professional advice.

Start With an Honest Documentation Audit

Before building workflows, find out how your current records would perform under RCD.

What to Audit

Select a random sample of recent 30-day billing periods, including both initial and subsequent periods, and review each one against the elements RCD reviewers examine:

• Homebound status. Does the record describe both criteria in Medicare's definition: a condition that requires supportive devices, special transportation, or another person's help, or makes leaving home medically contraindicated; and a normal inability to leave home, with leaving requiring a considerable and taxing effort?

• Physician or allowed practitioner care. Is the patient under the care of a physician or allowed practitioner?

• Plan of care. Is there a plan of care with the required elements, established and periodically reviewed, and signed and dated?

• Skilled need. Does the record show a need for intermittent skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy?

• Face-to-face encounter. Did the encounter occur within 90 days before or 30 days after the start of care? Was it related to the primary reason for home health? Was it performed by an allowed provider type? Did the certifying practitioner document the encounter date?

• Certification and recertification. Are certifications complete, signed, and dated?

• Supporting documentation from the referring or certifying practitioner. Does the practitioner's record, not only the HHA's record, support eligibility?

• Signatures. Are signatures valid, legible or supported by a signature log or attestation?

How to Use the Results

• Calculate the share of billing periods that would likely be fully affirmed.

• Identify the most common reasons for failure.

• Compare results with the 90 percent threshold.

• Use the findings to choose a review option and target training.

If the audit shows that many billing periods would fail, focus first on fixing the documentation problems, because both review options measure the same requirements.

Preparing for Choice 1: Pre-Claim Review

Understand the Process

According to the RCD Operational Guide:

• The HHA submits a pre-claim review request with supporting documentation any time before submitting the final claim for a 30-day billing period.

• Each request must include required data elements about the beneficiary, the certifying practitioner, the HHA, the submitter, and the billing period.

• The MAC makes a decision within 10 business days, excluding federal holidays, for initial requests and resubmissions.

• Decisions are provisionally affirmed, partially affirmed, or non-affirmed.

• Non-affirmed requests may be corrected and resubmitted, identified as a resubmission with the original UTN.

• Some requests are rejected without review, for reasons such as the wrong MAC, a beneficiary enrolled in Medicare Advantage or another plan, invalid identifiers, missing information, no clinical documentation, or another HHA already holding a UTN for the same period. Rejections are not counted as non-affirmations, but they delay the process.

• Claims submitted without a decision are stopped for prepayment review and, if payable, receive a 25 percent payment reduction that cannot be appealed.

The guide also describes rules on whether multiple billing periods may be submitted in a single request, and notes differences for California. Agencies should confirm current California-specific submission rules with Wellpoint Federal before the start date.

Build an Intake-to-Submission Workflow

• At referral, collect the face-to-face encounter documentation and the referring practitioner's records that support homebound status and skilled need.

• At start of care, complete the comprehensive assessment and develop the plan of care.

• Track the plan of care until it is signed and dated by the certifying practitioner.

• Use a pre-claim review checklist to confirm every required element before submission. Wellpoint Federal provides checklists and education on its website.

• Assemble the request packet in a consistent order.

• Submit through the MAC's portal or other approved method.

• Log the submission date and method.

• Track the decision deadline.

• Record the decision and UTN.

Design a Consistent Packet

A clear, organized packet helps reviewers find what they need. Consider this order:

• The request form or required data elements.

• Face-to-face encounter documentation.

• The certifying practitioner's records supporting homebound status and skilled need.

• Certification or recertification.

• Plan of care.

• Comprehensive assessment and visit notes supporting skilled need.

• Signature attestations or logs if needed.

Handle Non-Affirmations Quickly

• Read the detailed decision letter to understand the reason.

• Obtain missing or corrected documentation.

• Resubmit as soon as possible, marked as a resubmission with the original UTN.

• Track non-affirmation reasons to find patterns.

Protect the UTN

• Confirm your billing system can capture the 14-character UTN.

• Place the UTN on the claim in the correct location, whether the decision was affirmed or non-affirmed. The Operational Guide describes where the UTN goes on paper and electronic claims.

• Build a billing edit that holds any claim without a UTN.

Manage Transfers

Only one HHA may hold a pre-claim review decision for a beneficiary for a given billing period. The guide explains that if another agency takes over care without its own pre-claim decision, the claim may be subject to complex medical review. Build a process for checking for transfers and coordinating with other agencies.

Preparing for Choice 2: Postpayment Review

Understand the Process

According to the Operational Guide:

• The HHA submits claims normally, and the MAC pays them.

• The MAC sends an ADR for each claim.

• The HHA has 45 days to submit records.

• The MAC has 60 days to review and decide.

• Denied claims become overpayments recovered through the standard process, and the HHA keeps its appeal rights.

• If the HHA does not respond, the MAC issues a notice of overpayment and begins recovery.

Build an ADR Workflow

Under postpayment review, every claim generates an ADR, so volume will be high.

• Make sure ADRs reach the right place. Confirm correspondence addresses in PECOS and monitor the MAC portal and paper mail daily.

• Log every ADR with the claim, beneficiary, billing period, and due date.

• Assign responsibility for assembling records.

• Use the same documentation checklist as for pre-claim review.

• Submit records electronically when possible and keep proof of submission.

• Track decisions and denial reasons.

• Calendar appeal deadlines for denied claims.

Plan for Overpayments and Appeals

Postpayment denials create overpayments. Agencies should understand the demand letter process and the deadlines that matter most:

• Interest may accrue on unpaid overpayments.

• Filing a redetermination within 30 days of the demand letter, and a reconsideration within 60 days of the redetermination decision, limits recoupment during the first two appeal levels under 42 CFR 405.379.

• An extended repayment schedule under 42 CFR 401.607 may be available in cases of hardship.

Watch for Patterns

Because postpayment review results arrive after payment, an agency may not learn of a documentation problem until many claims have already been paid. Track results closely in the first weeks and correct problems quickly to avoid a growing list of denials.

Engaging Certifying Physicians and Practitioners

Certifying practitioners play a central role in RCD success. Their records must support eligibility, and their signatures must be timely.

• Share CMS's RCD letter for physicians and practitioners.

• Explain the face-to-face encounter requirement and what the encounter note must show.

• Explain the homebound criteria and how to document them.

• Ask for timely signatures on plans of care and certifications.

• Provide simple templates or checklists that practitioners can use.

• Identify a contact in each referring practice.

• Track turnaround times for signatures by practice.

Agencies may want to prioritize outreach to their highest-volume referral sources first.

Staffing and Training

Roles to Assign

• RCD coordinator, responsible for overall readiness and tracking.

• Intake staff, responsible for collecting referral documentation.

• Clinical reviewers, responsible for checking packets before submission.

• Billing staff, responsible for UTNs, claims, and ADRs.

• Physician relations staff, responsible for practitioner outreach.

Training Topics

• Medicare home health eligibility requirements.

• RCD process for the chosen option.

• Documentation checklists.

• Portal use.

• UTN handling.

• ADR response.

• Escalation procedures.

Capacity Planning

Estimate the number of billing periods per month and the time needed to assemble and review each packet. Plan staffing accordingly, including backups for vacations and turnover.

Cash-Flow Planning

Both options affect cash flow.

• Under pre-claim review, final claims may be delayed while waiting for decisions or resubmissions.

• Under postpayment review, claims are paid, but denials create overpayments that may be recouped.

Agencies should:

• Model cash flow under expected affirmation or approval rates.

• Maintain reserves or access to credit.

• Track days from start of care to final claim.

• Report RCD metrics to leadership weekly in the first months.

Technology and Systems

• Confirm portal access for multiple users.

• Configure the EHR to flag missing elements, such as face-to-face documentation and unsigned plans of care.

• Build billing edits for UTNs.

• Create a tracking log or dashboard for submissions, decisions, ADRs, and appeals.

• Make sure records can be exported quickly and completely.

A Week-by-Week Readiness Plan

Now Through November 15, 2026

• Read the CMS RCD page, Operational Guide, and FAQs.

• Register for Wellpoint Federal education.

• Conduct a documentation audit.

• Set up portal access.

• Assign an RCD coordinator.

November 16 to December 16, 2026: Selection Period

• Review audit results with leadership.

• Decide on a review choice.

• Make the selection on Wellpoint Federal's portal and save the confirmation.

• Begin physician and practitioner outreach.

• Draft workflows and checklists.

December 17, 2026, to January 17, 2027

• Train staff.

• Test workflows with sample packets.

• Configure EHR and billing edits.

• Finalize cash-flow plans.

• Continue outreach to referral sources.

January 18, 2027, and Beyond

• Begin submissions or ADR responses.

• Track every request, decision, and ADR.

• Review results weekly.

• Correct problems quickly.

• Monitor progress toward the 90 percent threshold over the six-month cycle.

Documentation Tips by Element

Homebound Status

• Describe the specific condition that restricts the patient's ability to leave home, such as shortness of breath, unsteady gait, or cognitive impairment.

• Describe the assistance needed, such as a walker, wheelchair, or help from another person.

• Describe the effort required to leave home, such as needing to rest after short distances.

• Avoid generic statements like "patient is homebound" without supporting detail.

• Keep homebound descriptions consistent across the referral records, assessment, and visit notes.

Face-to-Face Encounter

• Confirm the encounter date falls within the required window.

• Confirm the encounter addresses the primary reason the patient needs home health.

• Confirm the encounter was performed by an allowed provider type.

• Confirm the certifying practitioner documented the date of the encounter.

• Request the encounter note at referral, not after start of care, whenever possible.

Skilled Need

• Describe why the services require the skills of a nurse or therapist.

• Connect the skilled services to the patient's condition and goals.

• Document teaching, assessment, management, or therapy that requires skilled care.

Plan of Care

• Include all required elements under 42 CFR 409.43, such as the types, frequency, and duration of services, and the goals.

• Obtain the certifying practitioner's signature and date before the final claim is submitted.

• Document any verbal orders and their authentication.

Certification

• Confirm the certification includes the required statements about eligibility.

• Confirm signatures and dates are valid.

• For recertifications, confirm the continued need for services is documented.

Packet Quality Control Checklist

Before submitting a pre-claim review request or an ADR response, a second reviewer should confirm:

• The beneficiary's name, Medicare number, and date of birth match across all documents.

• The billing period dates are correct.

• The face-to-face encounter documentation is included and meets requirements.

• Homebound status and skilled need are supported in both the practitioner's and the agency's records.

• The plan of care is complete, signed, and dated.

• The certification or recertification is complete, signed, and dated.

• Signatures are legible or supported by an attestation or signature log.

• Pages are legible, in order, and complete.

• The submission is marked as initial or resubmission correctly.

Coordinating With Other Agencies and Settings

Many home health patients come from hospitals, skilled nursing facilities, or physician offices, and some move between agencies. Coordination matters under RCD.

• Ask discharging facilities for complete records, including the face-to-face encounter if it occurred during the stay.

• Check whether the beneficiary has recently been served by another HHA.

• If another agency holds a UTN for the same billing period, the request will be rejected, so verify before submitting.

• Build relationships with discharge planners so they understand the documentation requirements.

Lessons From Existing RCD States

RCD has operated in Illinois since 2019 and later in Ohio, Texas, North Carolina, Florida, and Oklahoma. CMS has periodically released results from the demonstration on its RCD page. Agencies preparing in California can learn from that experience:

• Review CMS's published RCD statistics and education materials.

• Use contractor checklists and education sessions, which reflect the most common documentation problems.

• Expect the first cycle to require the most effort, as workflows and physician relationships are built.

Measuring Success

• Affirmation rate (pre-claim review) or claim approval rate (postpayment review).

• Non-affirmation and denial reasons.

• Number of rejected requests.

• Turnaround time from start of care to submission.

• Turnaround time for practitioner signatures.

• ADR response timeliness.

• Days in accounts receivable.

Remember that, under the Operational Guide, the 90 percent threshold is based on at least 10 requests or claims in a six-month cycle, and only fully affirmed pre-claim decisions count toward the affirmation rate.

Common Pitfalls

• Waiting until January to build workflows.

• Submitting incomplete packets and relying on resubmissions.

• Not checking for transfers or other agencies holding a UTN.

• Billing claims without UTNs under pre-claim review.

• Missing ADR deadlines under postpayment review.

• Not tracking non-affirmation reasons.

• Overlooking the practitioner's records that support eligibility.

• Assuming the default option is acceptable without analysis.

A Hypothetical Example

A mid-sized Los Angeles County HHA audits 40 recent billing periods and finds that about 75 percent would likely be fully affirmed. The most common problems are face-to-face encounter notes that do not clearly relate to the primary reason for home health and plans of care signed late.

The agency selects pre-claim review because it wants feedback before billing. It assigns an RCD coordinator, builds an intake checklist that requires face-to-face documentation before start of care when possible, and meets with its five largest referral sources to explain the requirements. It also configures its EHR to flag unsigned plans of care after a set number of days and adds a billing edit that holds claims without UTNs.

In the first weeks of the demonstration, its affirmation rate is about 82 percent. Weekly reviews show most non-affirmations involve homebound documentation from one referral source. After targeted outreach to that practice, the agency's rate climbs above 90 percent by the end of the first cycle.

Frequently Asked Questions

When should we start preparing?

Now. The selection period begins November 16, 2026, and the demonstration starts with billing periods beginning on or after January 18, 2027.

How long does pre-claim review take?

The Operational Guide states that the MAC makes decisions within 10 business days for initial requests and resubmissions.

How long do we have to respond to postpayment ADRs?

45 days. The MAC then has 60 days to make a decision.

What happens if we bill without a pre-claim review decision?

The claim is stopped for prepayment review and, if payable, receives a 25 percent payment reduction that cannot be appealed.

Can we change our choice later?

After each six-month cycle, agencies that meet the 90 percent threshold may select from additional choices. Agencies that do not meet the threshold choose again from the initial options.

Conclusion

The January 2027 start of RCD in California leaves little time to prepare. Agencies that audit their documentation now, choose a review option based on evidence, build disciplined workflows for pre-claim review or postpayment ADRs, engage certifying practitioners, plan staffing and cash flow, and track results from the first day will give themselves the best chance of reaching the 90 percent threshold and earning reduced review.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps California home health agencies prepare for RCD through documentation audits, review choice analysis, pre-claim review and ADR workflow design, staff training, physician outreach materials, and affirmation rate tracking. If your agency needs help getting ready before January 18, 2027, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/review-choice-demonstration-for-home-health-services

• Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services Operational Guide. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/downloads/rcd-operational-guide.pdf

• Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services Frequently Asked Questions. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/downloads/rcd-faqs.pdf

• Federal Register Public Inspection. Agency Information Collection Activities: Review Choice Demonstration for Home Health Services, CMS-10599 (Document 2026-22297). https://public-inspection.federalregister.gov/2026-22297.pdf

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 7, Home Health Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

• Centers for Medicare & Medicaid Services. Additional Documentation Request. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• Electronic Code of Federal Regulations. 42 CFR 424.22, Requirements for Home Health Services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-B/section-424.22

• Electronic Code of Federal Regulations. 42 CFR 409.43, Plan of Care Requirements. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-409/subpart-E/section-409.43

• Electronic Code of Federal Regulations. 42 CFR 405.379, Limitation on Recoupment of Provider and Supplier Overpayments. https://www.ecfr.gov/current/title-42/section-405.379

• Electronic Code of Federal Regulations. 42 CFR 401.607, Claims Collection and Compromise. https://www.ecfr.gov/current/title-42/section-401.607