Understanding Denials and the Remedies for HH Status Claim Reason Code: 37253 Timely OASIS Submission to the QIES Data Base
Posted on Friday, September 15, 2017 1:21 PM
Many home health agencies have claims that are denied with reason code: 37253. Upon reconsideration, their claim is still denied. Following is a brief explanation why reconsiderations are being denied and some suggestions to assist you in getting claims paid.
1. The claim will be denied if the patient’s Medicare number on the final claim is different from the OASIS submission.
An example of this is a patient who was accessing their spouse’s Medicare benefits. If the spouse died during the episode, the patient’s Medicare number would be changed to reflect ‘widow or widower’ status. In other words, the patient’s revised Medicare number might have a ‘D’ as a suffix.
Medicare recognizes that at the time of the assessment, the Medicare number was correct. However, the system is not able to view the OASIS assessment if the Medicare numbers do not match at the time of billing. There is no guidance for this issue. Some suggestions for resolution:
• Have a very tight process – where on the first visit of each month of any patient ask the patient and caregiver if there have been any changes in insurance, or any new cards. Doing this as a standard requirement really attacks the issue head on since the systems only see the information they are fed.
• If the provider discovers this before final billing, the agency can submit a revised OASIS and correct the Medicare number. This would override the original, but the original submission date is still compliant.
• If the provider does not find out until Medicare denies the claim, then the provider needs to submit a reconsideration with the explanation and complete documentation.
2. When submitting reconsiderations, providers MUST submit ALL pages of their validation reports: not just the first page with the date of validation and the page with the patient information on it.
This requirement is not listed in the guidance to providers. If the provider does not submit ALL pages, they will get another denial. Providers should identify the patient in the report with a star or some indication which patient they are referring to.
3. Agencies must keep all pages of their Validation Reports. CMS cannot see validation reports in their systems and validation reports cannot be retrieved after the fact. If the provider does not keep their validation reports to submit with their reconsideration, there is nothing that can be done. Once the validation report is sent to the agency, it can no longer be retrieved.
4. If OASIS M0063 is left blank (Medicare # for the claim), the OASIS system will accept the OASIS assessment. There is no warning given to the provider that this field is blank. When the final bill is submitted it will be denied as there is no Medicare number for the claim in the OASIS system.
5. HIC #’s, CCN #s and NPI #s all must match: OASIS and claims.
6. M0100: reason for assessment - must be in correct sequence. Providers do get warnings on their validation reports if the sequence is not correct. But, if the sequencing error is not corrected, the claim will be denied. This reason code is telling providers that an OASIS assessment is missing.
7. All corrected OASIS must be submitted before the final claim. If the corrected OASIS is submitted after the final claim, then the claim will have wrong information. The system will not be able to cross reference the corrected OASIS and the claim will be denied.
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Written by Debbie Plesich RN BSN COS-C, Corridor’s Director of Operational / Regulatory Consulting.