RESOLVED: Some Claims Editing for Reason Code U537I, Home Health Claim Falls Outside Admission Period for Same Provider

Published 05/09/2025

RESOLVED: Home Health (HH) — Some Claims Editing for Reason Code U537I, HH Claim Falls Outside of an HH Admission Period for the Same Provider
Current Status Date  
Resolved May 7, 2025 Status: On April 21, 2025, CWF implemented a fix to prevent HH periods that have a Notice of Admission (NOA) indicator (admission period) from dropping off the beneficiary’s file. Instead CWF will drop the next oldest HH period that does not have an NOA indicator, resolving the issue going forward.

Provider Action: This issue affected claims with admission dates from January 1, 2022, and prior to April 21, 2022, and 37 or more consecutive periods in a single admission, with the same HHA, on a beneficiary’s eligibility record. If an HHA has a claim that meets the above criteria and it edited for U537I, you may contact the Provider Contact Center at 855–696–0705. 

Please note that reason code U537I assigns correctly if:

  • There is no admission on file for the beneficiary and HHA
     
  • The NOA was submitted but was returned to the provider/rejected
     
  • The NOA was cancelled by the HHA and never resubmitted
     
  • The admission date does not match on the NOA and claim; or
     
  • Another HHA admitted the beneficiary and submitted an NOA with Condition Code 47
     
  • If that admission was closed by another claim with an earlier service date(s)

If reason code U537I assigns for one of the above reasons, it was correct, and the HHA must resolve the edit by taking the appropriate actions.
Open  March 11, 2025 Status: This issue is in research.
    Provider Action: No provider actions are needed currently. We will provide an update as soon as it is available. 
Issue Description
This issue affects HH claims for patients that have been on HH for 37 or more consecutive periods in a single admission. The Common Working File (CWF) can only hold the 36 most recent periods of care for any beneficiary. Periods that precede the most recent 36 will be dropped off the file and are not retrievable online. When the admission period drops from CWF (also drops from the beneficiary’s eligibility record), claims for periods 37 and later cannot find the admission period and the claim is returned to provider (RTP) with reason code U537I, “The FROM and THROUGH dates on the HH claim fall outside of an HH Admission period for the same provider.” 

 


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