Healthcare Provider Solutions

The claim edit that has been in place since April 3, 2017 has been denying home health claims, at the point of billing, if the matching OASIS was not in the ASAP database. Some of these denials have been the result of data not matching between the claim and the OASIS, primarily the patient’s HIC number being different or the OASIS completion date being a mismatch between the OASIS and the treatment authorization code on the claim. CMS has issued a temporary solution for claims SUBMITTED October 6, 2017 and later:

Until matching errors are corrected, Medicare systems will Return to Provider (RTP) home health claims when no Outcome and Assessment Information Set (OASIS) is found. When these claims are returned with reason code 37253, use the F9 function to resubmit your claim after taking one of these actions:

  • Update the Health Insurance Claim (HIC) number on the OASIS assessment to match the current information
  • Correct the assessment completion date reported in the claim treatment authorization code to match the OASIS assessment
  • Resubmit for denial using condition code 21 and Type of Bill 320 if the assessment was not submitted
    • This means that agencies will need to edit the claim to reflect a denial because the OASIS was NOT in the database.

Agencies have already submitted questions regarding the last bullet above because they thought this meant that they would be able to submit the OASIS if it wasn’t there originally and that is NOT the case. All this update changes are allowing agencies to correct mismatches and resubmit versus having to file a redetermination. RTP (commonly referred to as T status) claims can be corrected within the Direct Data Entry (DDE) system under the Claims Correction option. This is the reference to using the F9 function to resubmit the claim. Agencies that typically retransmit claims through batch processing to correct a RTP claim versus using DDE will still be allowed to do so.

The current understanding is that this is temporary and once the system is updated to allow for mismatched data it will revert back to denial versus RTP. Any claims that were denied prior to October 6, 2017, will have to be appealed through redetermination.

As HPS has been warning for a few years, the time has come that agencies payment is being impacted by the lack of OASIS transmission confirmation.

Many home health agencies are continuing to trust that their home health software is protecting them from this edit due to the check marks or green lights on the claims regarding OASIS EXPORTING and recently we have discovered that one of the top home health software vendors in the industry does not even do that. The only way for this to be confirmed, prior to transmission of the claim, is for the agency to review the FINAL VALIDATION reports that result following the transmission of the OASIS.

One rude awakening that agencies are beginning to have is that if you receive a denial for the OASIS not being in the ASAP database there are no appeal rights. If indeed the OASIS was not in the database there is nothing to appeal.

Agencies need to ensure that someone is checking the OASIS Final Validation reports confirming that each and every Start of Care (SOC) and FollowUp/Recertification (FU) OASIS have been transmitted prior to transmitting the final claim for EACH and EVERY 60-day episode.