RCD: North Carolina and Florida Transition Cycle 4
As the Review Choice Demonstration (RCD) for home health agencies (HHA) in North Carolina and Florida 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, the provider 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
- 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 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
- Choice 3: Minimal postpayment 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 rate calculation period occurs during the month of July 2022, with result letters being sent to HHAs by the end of July 2022. The selection period for Cycle 4 will take place from August 1, 2022, through August 16, 2022. 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.
Transition Timeline
|
|
Cycle 1 |
Cycle 2 |
Cycle 3 |
Cycle 4 |
Cycle 5 |
Cycle 6 |
|---|---|---|---|---|---|---|
|
Cycle Start |
08/31/20 |
05/01/21 |
01/01/22 |
09/01/22 |
05/01/23 |
01/01/24 |
|
Cycle End |
02/28/21 |
10/31/21 |
06/30/22 |
02/28/23 |
10/31/23 |
05/31/24 |
|
Results Posted |
03/31/21 |
11/30/21 |
07/31/22 |
03/31/23 |
11/30/23 |
06/30/24 |
|
Selection Start |
04/01/21 |
12/01/21 |
08/01/22 |
04/01/23 |
12/01/23 |
|
|
Selection End |
04/15/21 |
12/14/21 |
08/16/22 |
04/16/23 |
12/14/23 |
|
As providers transition from Cycle 3 to Cycle 4, please be advised of the actions required when changing from one choice to another.
Important Note: Any claim with a date of service on or after 8/31/2020 is subject to the RCD program in North Carolina and Florida.
|
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 July and August will be included in the Cycle 4 results. |
|
Choice 1: PCR |
Choice 2: Postpayment Review |
1. Continue to submit PCR requests through 8/31/2022. Data from July and August will be included in the Cycle 4 results. a. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed). b. Respond to ADRs as generated
2. As of 9/1/2022, submit final claim. a. Final bill will adjust, and the ADR will generate b. Respond to ADR |
|
Choice 1: PCR |
Choice 3: Minimal Review |
1. Continue to submit PCR requests through 8/31/2022. Data from July and August will be included in the Cycle 4 results. a. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed). b. Respond to ADRs as generated
2. As of 9/1/2022, submit final claim. a. ADR will not generate. b. 25 percent reduction will apply |
|
Choice 1: PCR |
Choice 4: Selective Postpayment Review |
1. Continue to submit PCR requests through 8/31/2022. Data from July and August will be included in the Cycle 4 results. a. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed). b. Respond to ADRs as generated
2. As of 9/1/2022, submit final claim for payment. a. Final bill will be adjusted, and the ADR will generate b. Respond to ADR |
|
Choice 1: PCR |
Choice 5: Spot Check |
1. Continue to submit PCR requests through 8/31/2022. Data from July and August will be included in the Cycle 4 results. a. Add UTN to claims if PCR was submitted (regardless if affirmed or non-affirmed). b. Respond to ADRs as generated
2. As of 9/1/2022, submit final claim. a. ADR will generate b. Respond to ADR |
|
Choice 2: Post Payment Review |
Choice 1: PCR |
1. Continue to respond to ADRs. Data from July and August will be included in the Cycle 4 results. 2. Begin submitting PCR requests on 9/1/2022 for any claim that will be submitted on or after 9/1/2022 with a date of service on or after 8/31/2020. a. Add UTN to 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. 2. As of 9/1/2022, submit final claim a. ADR will not generate b. 25 percent reduction will apply |
|
Choice 2: Postpayment Review |
Choice 4: Selective Postpayment Review |
1. Continue to respond to ADRs. Data from July and August will be included in the Cycle 4 results. |
|
Choice 2: Postpayment Review |
Choice 5: Spot Check |
1. Continue to respond to ADRs. Data from July and August will be included in the Cycle 4 results. |
|
Choice 5: Spot Check |
Choice 1: PCR |
1. Continue to respond to ADRs. Data from July and August will be included in the Cycle 4 results. 2. Begin submitting PCR requests on 9/1/2022 for any claim that will be submitted on or after 9/1/2022 with a date of service on or after 8/31/2020. a. 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 July and August 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 9/1/2022, submit final claim a. ADR will not generate b. 25 percent reduction will apply |
|
Choice 5: Spot Check |
Choice 4: Selective Postpayment Review |
1. Continue to respond to ADRs. Data from July and August will be included in the Cycle 4 results. |
|
Choice 5: Spot Check |
Choice 5: Spot Check |
1. Continue to respond to ADRs. Data from July and August will be included in the Cycle 4 results. |