RCD and Appeals

The Review Choice Demonstration (RCD) does not include a separate appeal process for a non-affirmed pre-claim review decision. As a reminder, a non-affirmed pre-claim review decision does not prevent the home health agency (HHA) from submitting a final claim. A submission of a final claim with a non-affirmed unique tracking number (UTN) and resulting denial by the Medicare Administrative Contractor (MAC) would constitute an initial determination on the claim that would make the appeals process available for disputes by beneficiaries and HHAs. Appeals will follow all current procedures no matter which RCD choice an HHA selects.

Providers should remember that the 25 percent payment reduction cannot be appealed for pre-claim review or minimal review choice selections.

Helpful Tips

• Wait to file your claim until you receive the PCR decision letter containing the UTN for the provisionally affirmed HCPCS codes requested on the PCR
• If applicable, include the provisional affirmation letter with your appeal. This will speed up the appeal review process.
• If you disagree with a non-affirmed or partially affirmed PCR decision, a resubmission PCR request can be submitted for review

Visit Palmetto GBA's Appeals page for more resources and up to date information.

References

• Medicare Claims Processing Manual, Chapter 29 (PDF)
• CMS RCD Operational Guide (PDF)
• Medicare Parts A & B Appeals Process (PDF)