Background
General Information
IRF RCD cycle timelines
Choice 1 - Pre-claim review (PCR)
Choice 2 - Post payment review
IRF RCD review choice selection
IRF RCD affirmation/approval rate
Subsequent review choices
IRF RCD contact information
Educational opportunities
IRF RCD alerts
Quick links and resources
CMS is implementing a review choice demonstration (RCD) for inpatient rehabilitation facility (IRF) services in Pennsylvania.
As part of this demonstration, CMS initially allows IRFs to select one of two choices: Choice 1 - Pre-claim review (PCR) or Choice 2 - Post payment review, for all IRF services in the demonstration states. For either of the two choices selected, pre-claim or post payment review will be required for every IRF service.
Inpatient rehabilitation facility review choice demonstration (IRF RCD) guidelines
Question |
Answer |
Who |
The initial implementation of the IRF RCD for jurisdiction JL applies only to IRF providers physically located in Pennsylvania. |
What |
On May 15, 2023, the CMS announced information on the implementation of a RCD for IRF services, to offer more flexibility and choice for providers, as well as a risk-based approach to reward providers that show compliance with Medicare IRF policies and guidelines. The IRF RCD has a 5-year duration. On March 1, CMS announced the implementation of the IRF RCD expansion to include IRFs physically located in Pennsylvania. |
When |
At least 60 days prior to the implementation date for each state, CMS will announce the date the demonstration will begin. IRFs will have a 30-day choice selection period which will end two weeks prior to the start of the demonstration in their state to make their choice selection. IRF providers must make their selection in the free, secure internet portal Novitasphere. Pennsylvania IRF choice selection period begins on May 3, 2024, and ends June 2. The demonstration will apply to IRF admissions occurring on or after June 17. IRF admissions prior to June 17, are not part of the demonstration. |
Where |
The IRF RCD began August 21, 2023, for IRFs physically located in Alabama and bill to Palmetto GBA’s jurisdiction J (JJ) A/B MAC. The demonstration expanded to IRFs physically located in Pennsylvania and bill to Novitas' jurisdiction L (JL) A/B MAC on June 17. The demonstration will then expand to Texas and California. After the initial four states, CMS will expand the demonstration to include the IRFs that bill to and are in MAC jurisdictions JJ, JL, JH, and JE. At least a 60 days' notice will be provided before expansion into other states. |
Why |
CMS expects that creating a review choice process will ensure Medicare coverage and documentation requirements are likely met. This program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay medically necessary care to Medicare beneficiaries. This RCD protects our programs' sustainability for future generations by serving as a responsible steward of public funds. |
How |
CMS initially allows IRFs in the review demonstration to select one of two choices for all IRF services: Choice 1: Pre-claim review (PCR) IRF must request PCR for all stays. Claims submitted without PCR will undergo prepayment review. Affirmation rate is calculated every 6 months. Choice 2: Postpayment review IRF submits claims for each stay. Each claim is processed and paid per CMS procedures. MAC sends ADRs and follows CMS post payment review procedures. Approval rate is calculated every 6 months. For either of the two choices selected, 100% pre-claim or post payment review will be required for every IRF service in the demonstration. IRFs who do not actively select one of the initial two review choices will be automatically assigned to participate in choice 2: Post payment review. IRFs will be evaluated over a six-month review cycle. After a six-month period, IRFs demonstrating compliance with Medicare rules through their pre-claim review affirmation rate, or post payment review approval rate will have additional review choice selection options if they have met the targeted affirmation/approval rate or greater. IRFs may select from one of the three subsequent review choices: Choice 1: Continue with pre-claim review Choice 3: Selective postpayment review Choice 4: Spot check prepayment review References |
*Note: Continue to submit reviews based on current cycle review choice until the next review cycle start date.
Choice 1 - Pre-claim review (PCR) is when 100% of claims are reviewed prior to final claim submission. PCR is a process through which a request for provisional affirmation of coverage is submitted for review before the final claims are submitted for payment. PCR helps make sure that applicable coverage, payment, and coding rules are met before the final claim is submitted.
Choice 2 - Postpayment review is when 100% of claims are reviewed after final claim submission. The IRF will follow the standard intake, service, and billing procedures, and the claims will pay according to normal claim processes. The claim will be processed and paid per CMS guidelines. Novitas will send an additional documentation request (ADR) letter following payment of the claim. The IRF will submit medical records for review. Novitas will follow normal post payment review processes. If a claim is denied, Novitas will follow the standard payment recoupment procedure. The IRF retains all appeal rights for denied claims.
IRFs are required to make their review choice selection within the free, secure internet portal Novitasphere.
For Cycle 1, IRFs have a 30-day choice selection period that ends two weeks prior to the start of the demonstration in their state to make their review choice selection.
For subsequent cycles, IRFs have a 2-week choice selection period that ends two weeks prior to the start date of the subsequent cycle to make their review choice selection.
For information on review choice selection, review the article Inpatient Rehabilitation Facility Review Choice Demonstration (IRF RCD): Review Choice Selection Using Novitasphere
IRFs will be evaluated over a six-month review cycle. The affirmation threshold for the review cycle is the CMS determined minimum affirmation/approval rate for the cycle.
The affirmation rate is calculated by the number of requests affirmed/approved divided by the last instance for each unique beneficiary request (unique combination of PTAN / MBI / Admission date).
An IRF’s target affirmation rate is based on the following sliding scale from the time an IRF starts the demonstration:
First review cycle: 80% affirmation rate
Second review cycle: 85% affirmation rate
Third and subsequent review cycles: 90% affirmation rate
Any new IRFs will be subject to the target affirmation rate review cycle that their state has in process at that time.
Providers can access information about their affirmation/approval rate at any given time during the current or previous review cycle through the Cycle Stats option in Novitasphere.
For more information refer to:
Every six months, IRFs meeting or exceeding the target affirmation/approval rate may select one of the three subsequent review choices.
Choice 1: Pre-Claim Review
The IRF may begin or continue participating in PCR for a 6-month period.
Choice 3: Selective Postpayment Review
Under this choice the IRF will render services and submit claims according to their normal process. Every 6 months the MAC will select for postpayment review a statistically valid random sample of claims, based on the previous six month’s claim volume.
Choice 4: Spot Check Prepayment Review
Under this choice, the MAC will select a random sample of 5% of an IRF’s submitted claims, based on their previous six month’s claim volume, for pre-payment review, to ensure continued compliance.
For more information, review the article Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD): Transitioning from Cycle 1 to Cycle 2.
IRF customer service phone number:
855-340-5975 available Monday – Friday, 8 a.m. – 6 p.m. ET
Fax number:
844-599-9713
Mailing address:
Novitas Solutions
Attention: JL IRF RCD
PO. Box 3702
Mechanicsburg, PA 17055
Priority mailing address:
Novitas Solutions
Attention: JL IRF RCD
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
Register to participate in free, live webinars.
CMS recently expanded the review choice demonstration (RCD) for inpatient rehabilitation facility (IRF) services to Pennsylvania starting with admissions occurring on and after June 17. Novitas, the MAC for Pennsylvania, will conduct a pre-claim or post payment review of IRF services depending on your selection. Novitas will host a series of webinars to prepare your facility for this review process. You and your team are highly encouraged to attend.
Date |
Eastern time (ET) |
Event title |
Registration options |
Webinar Link* |
Thursday, May 2, 2024 |
Start: 10:00 a.m. End 11:30 a.m. |
Inpatient rehabilitation facility (IRF) review choice demonstration (RCD): Review choice selection and process Our second webinar within the series will provide an overview of the RCD and provide guidance on the review choice selection and the pre-claim and post payment review submission process. |
This event is intended for participating Pennsylvania IRF providers. |
View recording |
Friday, May 3, 2024 |
Start: 10:00 a.m. End 11:0 a.m. |
Inpatient rehabilitation facility (IRF) review choice demonstration (RCD): How to prepare Join us for an informational webinar to review the program requirements and expectations of the IRF RCD and learn more about how to prepare. |
This event is open to all JH and JL IRF providers interested in learning about the IRF RCD program. |
|
Tuesday, June 4, 2024 |
Start: 10:00 a.m. End 11:30 a.m. |
Inpatient rehabilitation facility (IRF) review choice demonstration (RCD): Review choice process Our third webinar within the series will provide an overview of RCD and the pre-claim and post payment review submission process, including what to include in your submission using the medical review checklists. |
This event is intended for participating Pennsylvania IRF providers. |
|
Tuesday, August 6, 2024 |
Start: 1:00 p.m. End 2:30 p.m. |
Inpatient rehabilitation facility (IRF) review choice demonstration (RCD): Cycle 1 progress This webinar provides up-to-date information on IRF RCD as we progress through reviews in Cycle 1. We will review common questions, observations and trends related to IRF RCD including the top reasons for non-affirmations. Our IRF RCD clinical team will be available to answer questions. You and your team are encouraged to attend. |
This event is intended for participating Pennsylvania IRF providers. |
|
Wednesday, October 2, 2024 |
Start: 1:00 p.m. End 2:30 p.m. |
Inpatient rehabilitation facility (IRF) review choice demonstration (RCD): Cycle 1 progress Join us for up-to-date information on IRF RCD as we progress through reviews in Cycle 1. We will review common questions, observations and trends related to IRF RCD including the top reasons for non-affirmations. Our IRF RCD clinical team will be available to answer questions. You and your team are encouraged to attend. |
This event is intended for participating Pennsylvania IRF providers. |
|
Wednesday, December 18, 2024 |
Start: 10:00 a.m. End 11:30 a.m. |
Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD): Cycle 1 Progress and Transitioning to Cycle 2 Join us for up-to-date information on IRF RCD as we progress through reviews in Cycle 1. We will review hot topics and trends related to IRF RCD including the top reasons for non-affirmations. We provide guidance on transitioning from Cycle 1 to Cycle 2 including Cycle 1 affirmation rate calculation and Cycle 2 review choice options. Our IRF RCD clinical team will be available to answer questions. You and your team are encouraged to attend. |
This event is intended for participating Pennsylvania IRF providers. |
|
Thursday, December 19, 2024 |
Start: 1:00 p.m. End 2:30 p.m. |
Inpatient rehabilitation facility (IRF) review choice demonstration (RCD): How to prepare Join us for an informational webinar to review the program requirements and expectations of the IRF RCD and learn more about how to prepare. |
This event is open to all JH and JL IRF providers interested in learning about the IRF RCD program. |
|
Thursday, January 23, 2025 |
Start: 10:00 a.m. End 11:30 a.m. |
Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD): Cycle 1 Review Stats and Transitioning to Cycle 2 Join us for up-to-date information on IRF RCD. During this webinar we will review the Cycle 1 results, top issued identified and how to view cycle stats. We will provide guidance on transitioning from Cycle 1 to Cycle 2 including the Cycle 2 review choice options and selection process. Our IRF RCD clinical team will be available to answer questions. You and your team are encouraged to attend. |
This event is intended for participating Pennsylvania IRF providers. |
|
*Webinar recordings are viewed on the Cisco WebEx platform. A new tab will open in your browser when you select the 'View recording' option. Select the play icon to start the recording. Note: CEUs are only available for live webinars; CEUs will not be awarded for viewed recordings.
If you are a Pennsylvania IRF participating in the RCD and would like to request outreach and education or more information regarding the program from Novitas, please submit a request to our education mailbox at Education@novitas-solutions.com. We will contact you within five business days of receipt of your request to coordinate a training session.
Guidance on issues identified by the IRF RCD clinical team will be listed when applicable.
Delays in claim processing have been identified. Novitas will have the delay in claims processing corrected August 5. Please note the following:
If the claim was submitted without the unique tracking number (UTN), the Novitas team will add the UTN so the claim can continue processing and the additional documentation request (ADR) letter can be discarded. After August 5, any claim in which the UTN is not added will return to provider (RTP) for correction. Claims submitted with the UTNs are not impacted.
If the claim submitted was for Medicare Advantage, the claim will be released and process as normal and the ADR letter can be discarded. After August 5, any claim submitted for the Medicare Advantage plan will process as they have historically.
Any claim that does not fit the above scenarios for which an ADR letter was received, the provider should respond to the ADR letter.
If you feel the claim was sent an ADR letter in error and does not fit the above scenarios, please reach out to the IRF Customer Service at 1-855-340-5975.
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