IRF RCD Choice Selection Definitions and Processes

Published 07/07/2023

Inpatient Rehabilitation Facilities (IRFs) are subject to the Review Choice Demonstration (RCD). Medicare Administrative Contractors (MACs) are required to review an IRF’s documentation to determine if beneficiaries meet IRF admission requirements per the Medicare Benefit Policy Manual (PDF).

What Is the Pre-Claim Review Option?

Choice 1: Pre-claim review is a process through which a request for provisional affirmation of coverage is submitted for review before the final claims are submitted for payment. Pre-claim review helps make sure that applicable coverage, payment, and coding rules are met before the final claim is submitted. Under pre-claim review, the provider submits the pre-claim review request and receives the decision prior to claim submission; however, the provider will begin services before submitting the request. A Unique Tracking Number (UTN) must be submitted on the claim, or it will result in a pre-payment ADR.

What Is the Postpayment Review Option?

Choice 2: Postpayment review is when 100 percent of claims are reviewed after the final claim submission. Under postpayment review, the provider submits the claim for each admission. The claim will be processed and paid per CMS guidelines; however, the Medicare Administrative Contractor (MAC) will send an ADR and follow CMS postpayment review procedures.

What Is the Selective Postpayment Review Option?

Choice 3: Selective postpayment is a statistically valid percentage of random claims that are reviewed every six months based upon the previous six months of claim volume. Under this choice, the MAC selects a statistically valid random sample (SVRS) every six months. The MAC sends ADRs and follows CMS postpayment review procedures.

What Is the Spot Check Review Option?

Choice 4
: Under Spot Check review, the MAC selects 5 percent of IRF claims every six months, based upon the previous six months of claim volume. The MAC sends ADRs and follows CMS prepayment review procedures.

Pre-Claim Review Process
The IRF submits a pre-claim review request to their MAC. 

  • The MAC will review the request 
  • The MAC will communicate a decision via telephone within two business days and in writing within 10 business days
    • A provisional affirmed decision means the claim will be paid as long as all other Medicare requirements are met
    • A non-affirmed decision means the request did not demonstrate that Medicare requirements were met

If a pre-claim review request is non-affirmed:

  • Resolve the non-affirmative reasons and resubmit the pre-claim review request
    • Unlimited resubmissions are allowed prior to the submission of the claim
    • Same review timeframe applies
  • The claim can be submitted and denied
    • Standard claims appeals process will apply

If no pre-claim review request was submitted, the claim will be subjected to prepayment medical review

  • Decision letters are sent to both the requestor and the beneficiary
  • They include a Unique Tracking Number (UTN) that must be submitted on the claim
  • Non-affirmations will provide details on which policy requirement(s) was/were not met

Postpayment Review Process

  • The IRF will follow the standard intake, service, and billing procedures, and the claims will pay according to normal claim processes
  • The MAC will send an ADR letter following receipt of the claim 
  • The MAC will follow normal postpayment review processes
  • IRFs who do not select an initial choice will default to this option

Selective Postpayment Review Process 

  • The IRF will follow the standard intake, service, and billing procedures, and the claims will pay according to normal claim processes 
  • The MAC will select a statistically valid random sample (SVRS) based on the previous six months’ claim volume 
  • The MAC will send the IRF an ADR letter and follow CMS postpayment review procedures

Spot Check Prepayment Review Process

  • The IRF will follow the standard intake, service, and billing procedures
  • The MAC will randomly select 5 percent of the submitted claims based on the previous six months’ claim volume
  • The IRF’s compliance determines future review choices
  • IRFs must meet the target review affirmation/approval rate threshold to be eligible for a subsequent review choice

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