Understanding Reason Code 37253 on Home Health Claims

(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)

  • If the CCN (six digit Medicare provider number) submitted on the OASIS does not match the CCN stored in QIES, a warning message will be displayed on the validation report. Submit a corrected OASIS to address the error before submitting the final claim
  • When the final/end of episode claim is submitted, the National Provider Identifier (NPI) number entered on the claim will automatically enter the CCN in the OSCAR field. This number must match what was transmitted on the OASIS. If the number does not match, the claim will RTP. Verify that the CCN submitted on the OASIS was correct. If not, submit a corrected OASIS and retransmit the claim. If the CCN submitted on the OASIS was correct, then verify the CCN submitted on the claim. If the claim was submitted with the incorrect CCN, a new claim will need to be submitted with the correct CCN.

2. Beneficiary Medicare Number (OASIS item M0063)

  • If OASIS item M0063 is left blank when the OASIS is transmitted, the QIES will accept the OASIS and will not generate a warning message. However, when the final/end of episode claim is submitted, the system will be unable to locate a corresponding OASIS, which will result in the claim being RTP. A corrected/modified OASIS should be submitted/transmitted to QIES before the final claim is submitted to Medicare. If the claim is RTP, submit a corrected OASIS before retransmitting the claim.
  • If the patient's Medicare ID Number transmitted on the OASIS does not match the number stored in QIES, a warning message will appear on the validation report to alert the provider of a mismatch. Verify if the Medicare ID transmitted on the OASIS is correct. If not, submit a corrected OASIS to address the error before submitting the final claim. If the Medicare ID transmitted on the OASIS is correct, verify that it matches the Medicare ID that is submitted on the claim. If not, submit a corrected OASIS and retransmit the claim. 
  • If the patient’s Medicare ID number transmitted on the OASIS matches the number stored in QIES, the OASIS will be accepted and no warning message will be received. Verify that the patient’s Medicare ID Number submitted on the OASIS matches the Medicare ID Number that was submitted and/or processed on the claim (this can be done by reviewing the remittance advice and/or checking claim page one of the Direct Data Entry (DDE) system). If the Medicare ID on the claim does not match the ID transmitted on the OASIS, submit a corrected OASIS and retransmit the claim.
    • Providers are also encouraged to validate a beneficiary/patient's Medicare eligibility records periodically
    • Changes to a Medicare ID will be reflected on page one of HIQA or HIQH in the “CORRECT” field

3. Assessment Completion Date (OASIS item M0090)

  • Ensure that the OASIS is transmitted and accepted in QIES before the final claim is billed. If the OASIS was transmitted late (after the 30-day time requirement) and no fatal errors exist, the OASIS will be accepted, but a warning message will be on the validation report stating that the OASIS was late. There is no corrective action that can be taken when the OASIS was submitted late.
  • If the claim is filed after the OASIS is transmitted and the system finds a corresponding OASIS, the claim will be processed
  • If the final claim is filed before the OASIS is transmitted, and the claim receipt date is more than 40 days from the OASIS completion date reported on the claim (see examples above), the claim will RTP. Since the submission of the OASIS is a condition of payment, providers should not retransmit the claim for payment. If the HHA determines the claim did not meet the condition of payment, the HHA shall bill for denial using the following coding:
    • Type of Bill (TOB) 0320 indicating the expectation of a full denial for the billing period
    • Occurrence span code 77 with span dates matching the From/Through dates of the claim, indicating the HHA’s acknowledgment of liability for the billing period
    • Condition code D2, indicating that the HHA is changing the billing for the Health Insurance Prospective Payment System (HIPPS) code to non-covered.
      • Note: Do not use condition code 21 in this case, since it would result in inappropriate beneficiary liability
  • If the final claim is filed before the OASIS is transmitted, and the claim receipt date is less than 40 days from the OASIS completion date reported on the claim, the claim will process as normal

4. Reason for Assessment (OASIS item M0100)

  • Ensure that this item is equal to 01, 03 or 04. An out-of-sequence warning message will appear on the validation report if this item is not correct. Submit a corrected OASIS to address the error before submitting the final claim. If the claim is RTP, submit a corrected OASIS and retransmit the claim.
  • Before the final claim (also known as an End of Episode or EOE claim) is submitted, providers should review their OASIS validation reports to ensure that the OASIS was transmitted and accepted. If there are fatal errors, the OASIS will be rejected. For minor errors, the OASIS may be accepted, but the validation report will contain warning messages. Providers are encouraged to submit a corrected OASIS, when appropriate, to address the errors by submitting a corrected/modified OASIS.

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

Example 1:

Episode DatesClaim Receipt DateTreatment Authorization CodeOASIS Completion DateOASIS Transmission Date
02/15/2017 – 04/12/2017 04/21/2017 16NS17BT41ERGGCMEC 02/15/2017 None

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.

Example 2:

Episode DatesClaim Receipt DateTreatment Authorization Code
OASIS Completion Date
OASIS Transmission Date
 
02/02/2017 – 04/02/2017
04/03/2017
16IK17BF42EOCFCKCC
02/1/2017 05/08/2017

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.

Example 3
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”. 

Episode DatesClaim Receipt DateTreatment Authorization Code
OASIS Completion Date
OASIS Transmission Date
 
02/20/2017 – 04/12/2017
04/21/2017
16NS17BT41ERGGCMEC
02/15/2017
02/20/2017

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. 

Example 4
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.

Episode DatesClaim Receipt DateTreatment Authorization Code
OASIS Completion Date
OASIS Transmission Date
 
03/23/2017 – 04/06/2017
05/22/2017
17DE17DE11BRCGAMCC
03/23/2017
04/28/2017

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:

  • A copy of the full OASIS transmission/validation report for the initial/original OASIS that corresponds with the episode dates on the claim
  • A copy of the full transmission/validation report for the corrected/modified OASIS, if applicable
  • Identify the record number that relates to the claim that was denied on your redetermination request. This can be done by entering the record number on the Redetermination Request Form, placing an asterisk, drawing a box or other identifying marks next to the record number on the validation report.
  • Providers may, but are not required to, block all patient information on the transmission/validation report that does not apply to the claim that was denied. However, the full transmission/validation report must be submitted with the request for a Redetermination.
  • A hardcopy of the OASIS (recommended)

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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