What's the difference between pre-claim review and postpayment review under the California Review Choice Demonstration?

Pre-claim review lets you submit documentation before filing a final claim, so any gaps can be corrected before payment is on the line. Postpayment review keeps your current billing workflow intact but exposes you to recoupments after payment has already been made — with no correction window to fix documentation before money changes hands.

What happens if a California home health agency doesn't make a selection before the December 16, 2026 deadline?

Agencies that miss the selection window are automatically placed into postpayment review by CMS — there's no neutral default. If you want to choose pre-claim review, that decision must be made deliberately before December 16, 2026.

How do I get my California home health agency to the 90% provisional affirmation rate required for reduced oversight?

The 90% threshold counts only full provisional affirmations — partial approvals and resubmissions that eventually resolved do not count toward it. Nine out of every ten submitted requests need clean documentation from the start, which means homebound status, face-to-face encounter records, plan of care certification, OASIS assessments, and clinical notes all need to be complete and internally consistent before the request goes in.

Can AI documentation tools like Andy help home health agencies meet Review Choice Demonstration requirements in California?

Yes. Andy drafts the full chart — including OASIS, clinical narrative, wound, and medication documentation — before the nurse leaves the driveway, then runs AI-assisted QA to catch missing elements and inconsistencies before anything is submitted. Agencies using Andy see up to 45% more detailed charts, which is the kind of documentation depth that holds up under MAC review whether you're in pre-claim or postpayment review.

What does the Review Choice Demonstration cover in California?

The RCD applies only to traditional Medicare fee-for-service home health claims billed under MAC Jurisdiction 6 (Wellpoint Federal). Medicare Advantage, Medicaid, and other payer types fall outside its scope, and billing runs in 30-day periods under PDGM, so each period of care is its own reviewable claim.

Which documentation gaps are most likely to trigger a non-affirmation under the Review Choice Demonstration in California?

Insufficient documentation drove 51.4% of home health improper payments in 2024, and medical necessity issues accounted for another 33.7%, so those are the two areas reviewers focus on most. Specifically, weak homebound status narratives, missing or late physician face-to-face signatures, OASIS assessments that conflict with coded diagnoses, and clinical notes that fail to connect each visit to a skilled need are the most common failure points.

Does the Review Choice Demonstration in California apply to Medicare Advantage patients?

No — the RCD covers only traditional Medicare fee-for-service home health claims billed under MAC Jurisdiction 6 (Wellpoint Federal). Medicare Advantage, Medicaid, and other payer types fall entirely outside the demonstration's scope.

How long does Wellpoint Federal take to return a pre-claim review decision for California home health agencies?

The blog does not specify an exact turnaround time for Wellpoint Federal's pre-claim review decisions, so your agency should check the current RCD Operational Guide or contact Wellpoint Federal directly for processing timeframes. What matters for cash flow planning is that the review happens before the final claim is filed, so a short processing window needs to be built into your billing cycle.

Can a California home health agency switch from postpayment review to pre-claim review after the demonstration starts in January 2027?

The blog does not detail mid-demonstration switching rules, so agencies should consult the RCD Operational Guide or reach out to Wellpoint Federal for the most current guidance on changing review paths. The safest move is to make a deliberate selection before the December 16, 2026 deadline rather than defaulting and hoping to course-correct later.

What staffing changes does a home health agency need to make to handle pre-claim review submission volumes?

Pre-claim review requires someone to compile and submit a documentation packet — physician certification, plan of care, face-to-face records, OASIS assessments, and clinical notes — before each final claim goes in. If your billing team is already stretched, that added step needs a clearly assigned owner, or the process breaks down at scale.

How does PDGM affect how many claims a California agency will have reviewed under the RCD?

Under PDGM, home health is billed in 30-day periods of care, so each period is its own billable unit subject to review. A patient receiving ongoing care across several months could generate multiple separately reviewable claims, which means high-volume agencies will face review on more individual claims than they would have under the older 60-day episode structure.

Should a California home health agency choose pre-claim review or postpayment review if its QA process is under-resourced?

An under-resourced QA function is a strong signal to think carefully about pre-claim review — the correction window it offers before payment is at risk is exactly the safety net agencies with inconsistent documentation need most. That said, choosing pre-claim review without fixing underlying documentation quality just delays the same problems, so the two decisions should be made together.

What's the fastest way for a California home health agency to get ready for the Review Choice Demonstration before the January 2027 go-live?

Start by auditing your most recent charts against the five core documentation requirements: homebound status narrative, face-to-face encounter records, plan of care certification, OASIS consistency, and clinical notes tied to a skilled need. Agencies that identify and close those gaps before January 2027 will be in the best position to clear the 90% provisional affirmation threshold within the first six months.

How does the Review Choice Demonstration differ from prior authorization for home health services?

Prior authorization requires approval before services can begin; the RCD does not block treatment while a pre-claim review is pending, so agencies can start or continue care before receiving a provisional affirmation decision. The RCD is a documentation review program, not a service-access gatekeeper.

Why is California being added to the Review Choice Demonstration now?

CMS identified California as a hotspot for hospice and home health fraud, making it a targeted expansion of a program already running in other states. All California home health agencies billing under MAC Jurisdiction 6 (Wellpoint Federal) are now in scope, with the demonstration applying to billing periods beginning on or after January 18, 2027.

CA Home Health RCD Nov 2026

On November 2, 2026, CMS announced that Review Choice Demonstration will expand to California starting January 18, 2027.

What Is the Review Choice Demonstration?

Review Choice Demonstration (RCD) is a CMS program designed to verify that home health agencies are meeting Medicare requirements. Through RCD, agencies gain more predictability in cash flow and can reduce post-payment audits. Agencies that show consistent compliance earn progressively lighter oversight over time. Those that can't stay under closer scrutiny.

Which Review Choice To Choose?

Andy recommends selecting Pre-Claim Review before December 16, 2026. Pre-claim review on 100% of notes helps agencies quickly put the right processes in place to ensure high affirmation rates. Post-payment review in contrast happens months later when it's too late to change course.

RCD does not add new requirements, only additional oversight to ensure agencies are meeting existing requirements related to F2F, homebound status, and skilled need.

Pre-Claim Review: Agencies submit documentation for an affirmation for each 30-day period, before billing.
Post-Payment Review: Agencies bill normally, then all claims are pulled for a post-payment audit. Agencies are at risk of a recoupment of overpayment.

Key Dates and Timeline for California Agencies

Please keep in mind the December 16, 2026 deadline. If your agency hasn't made a selection by then, CMS places you into postpayment review by default.

Date	Milestone
November 16, 2026	Selection period opens
December 16, 2026	Selection period closes, default enrollment if no selection made
January 18, 2027	RCD goes live for billing periods on or after this date

Claims and Services Subject to the Demonstration

RCD applies to traditional Medicare fee-for-service home health claims only. Medicare Advantage plans, Medicaid, and other payer types fall outside the scope.

How to Qualify for Reduced Oversight

After six months, agencies that hit the compliance threshold can qualify for lighter oversight. The bar is 90% full provisional affirmation rate based on a minimum of 10 submitted requests or claims.

Agencies that clear that threshold become eligible for one of 3 reduced review options. Selective post-payment review is the default if you do not choose.

Pre-Claim Review: Agencies may continue 100% pre-claim review
Selective post-payment review: Your Medicare Administrative Contractor (MAC) pulls a statistically valid random sample of claims every 6 months
Spot check review: Your MAC selects a random 5% of home health claims for pre-payment review

Documentation Requirements That Drive RCD Outcomes

RCD uses the same documentation CMS has always required for Medicare home health billing. Reviews will focus on:

Face-to-face encounter records signed and dated by the certifying physician
Homebound status documentation showing the patient's condition and why leaving home requires considerable effort
Clinical documentation demonstrating medical necessity and skilled need

How Andy Supports California Agencies Preparing for the RCD

Andy helps users meet RCD requirements. Field clinicians record their visits through the app, and Andy documents the OASIS with clear homebound statement and medical necessity. Every chart then goes through AI-assisted QA that catches inconsistencies, flags missing elements, and checks that homebound status and skilled need are clearly supported. Afterwards, home health coders review each note for adequate F2F documentation.

If you're a California agency figuring out your RCD strategy before the December 16 deadline, we'd be glad to show you how Andy works.