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Printed Date: 9/22/2015
(No matching OASIS found and the claim receipt date is more than 40 days after the OASIS completion date)
Medicare regulations require that the Outcome and Assessment Information Set (OASIS) be transmitted to the state repository, known as the Quality Improvement Evaluation System (QIES), within 30 days of the date the OASIS is completed. Change Request (CR) 9585 was implemented with the April, 2017, quarterly systems release and applies to all home health claims with episodes that end on or after April 1, 2017. In accordance with CR 9585, home health claims with dates of service on or after April 1, 2017, that are submitted for payment will deny with Reason Code 37253 when a corresponding OASIS cannot be found in the CMS repository and the claim receipt date is more than 40 days from the OASIS completion date reported on the claim. Positions 5 to 8 of the Treatment Authorization Code on the claim represent the OASIS completion date as reported in item set M0090.
Effective with claims received on or after October 6, 2017, when a corresponding OASIS is not found, the claim will be Returned to the Provider (RTP) for correction. A claim that is RTP cannot be appealed. Providers must make the necessary corrections as outlined below and retransmit the claim.
A corresponding OASIS means one that matches the four criteria below.
1. HHA CCN (OASIS item M0010)
2. Beneficiary Medicare Number (OASIS item M0063)
3. Assessment Completion Date (OASIS item M0090)
4. Reason for Assessment (OASIS item M0100)
The following are some examples of situations for which received reason code 37253 as a result of the system changes that were implemented with CR 9585. These examples are for educational purposes only and do not limit other situations for which reason code 37253 may be applied to a claim
Positions 5 and 6 of the Treatment Authorization Code referenced above reflect “17” for the year 2017 and positions 7 and 8 reflect “BT” for the month of February and the 15th day of the month. For this example, the claim processed correctly because no OASIS was found in QIES, and the claim was received more than 40 days after the OASIS completion date. The OASIS should have been transmitted no later than March 26, 2017.
Positions 5 and 6 of the Treatment Authorization Code referenced above reflect “17” for the year 2017 and positions 7 and 8 reflect “BF” for the month of February and the first day of the month. For this example, the claim processed correctly. Although the provider was permitted to transmit the OASIS late, the OASIS was not found in QIES when the claim was received, and the claim receipt date was more than 40 days from the OASIS completion date of February 1, 2017. The OASIS should have been transmitted no later than March 12, 2017.
Patient's Medicare ID number submitted on the OASIS had a “B” on the suffix, but the beneficiary's/patient's Medicare records reflected that the Medicare ID number changed the suffix to a “D”.
Positions 5 and 6 of the Treatment Authorization Code referenced above reflect “17” for the year 2017 and positions 7 and 8 reflect “BT” for the month of February and the fifteenth day of the month. When a patient's Medicare records reflect a corrected Medicare ID number, the Fiscal Intermediary Standard System (FISS) will automatically cross-reference the claim to the correct Medicare ID number and process the claim accordingly. The QIES will process the OASIS with the Medicare ID number that was initially transmitted. Therefore, in this example, when the system was searching for the OASIS, no OASIS was found with the “D” suffix, and the OASIS completion date on the claim was more than 40 days from the claim receipt date.
HHS CMS Certification Number (CCN), also known as the Medicare Provider Transaction Access Number (PTAN) or OSCAR number that was submitted on the OASIS does not match the CCN submitted on the claim.
Positions 5 and 6 of the Treatment Authorization Code referenced above reflect “17” for the year 2017 and positions 7 and 8 reflect “DE” for the month of March and the twenty-third day of the month. The OASIS was transmitted prior to the receipt date on the claim. However, the HHS CCN transmitted on the OASIS did not match the CCN submitted on the claim. The provider's validation report identified a warning message stating that the CCN was incorrect.
For claims that were received and denied prior to October 6, 2017, providers have the right to appeal the denial. However, providers are encouraged to ensure that the above criteria are met before requesting a redetermination. A request for a redetermination may be submitted through the eServices online provider portal or by completing the Redetermination Request form (PDF, 196 KB). The Redetermination Request must be received within 120 days of the date of the remittance advice and include the following:
Note: The submission of either the transmission/validation report and/or a hardcopy OASIS does not guarantee a reversal of the denial. The information from these documents is used for verification purposes.
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Last Updated: 06/04/2019