Pre-Claim Review (PCR) Affirmation/Claim Approval Rate Calculation

When a provider transitions from one cycle to the next, there are two months of decisions between Cycles that will be included in the rate for the subsequent cycle. This includes providers that move from a Pre-Claim Review (PCR) option to an Additional Documentation Request (ADR) option, or from an ADR option to a PCR option.

Example:

In the example above, the two months between Cycle 1 and Cycle 2 are the months of October and November. The data from the two months between Cycles will be combined into one rate, known as the PCR Affirmation/Claim Approval rate, which will be included in your next Cycle results.

To ensure providers receive credit for all decisions, the RCD rates are combined into one PCR Affirmation/Claim Approval Rate. All decisions rendered following the end of one cycle, regardless of type (i.e., PCR or ADR), are included in the calculations for the next cycle.

Reminder: There are no recalculations to incorporate Appeals decisions for the RCD end of cycle results.