Module 1, Topic 1
In Progress

Day 3: Common Rejections

Petria September 3, 2020

Common Rejection Problems

Top Claim Submission Errors (Reason Codes) & How to Resolve

Claim submission errors will cause claims to either reject or move to your Return to Provider (RTP) file for correction.

Below is a list of the top RTP and reject errors. Let’s look at how to resolve each one.

 

 

Reason Code 38107:
Home health final claim submitted; however, a processed, matching RAP cannot be found.

  • Prior to submitting the final claim, access FISS Claim Inquiry option (Option 12) to determine if the RAP is in FISS status/location (S/LOC) P B9997
    • You should not submit the final claim for the episode unless the RAP is in this S/LOC
  • Review your Medicare Remittance Advice timely to verify the RAP has completed processing
  • Submit the final claim timely according to regulations under the Home Health Prospective Payment System (HH PPS) and the Patient Driven Groupings Model (PDGM) based on the dates of service of the claim.
    • Under HH PPS, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the episode
    • Under PDGM for periods of care beginning January 1, 2020, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the 30-day period of care.
  • Prior to submitting the final claim, ensure the RAP has not auto-canceled
  • Prior to submitting the final claim, ensure that the key information, listed below, for the episode’s RAP and claim matches.
    • Provider number/identifier of the billing home health agency (FL 56)
    • “FROM” date of the episode (FL 6)
    • Date of admission (FL 12)
    • Health Insurance Prospective Payment System (HIPPS) code (FL 44)
    • Date of service billed with the HIPPS code (FL 45)

 

 

Reason Code 38157:

The Fiscal Intermediary Standard System (FISS) has found a previously submitted billing transaction for the same beneficiary and dates of service with the same provider number; therefore, the second billing transaction submitted by the provider is a duplicate.

 

 

Reason Code 37253:
This reason code is assigned when there is no corresponding OASIS assessment found in Medicare’s systems related to the claim.

Before submitting your claim review the OASIS Final Validation Report (FVR) to ensure the OASIS assessment was successfully accepted. On the next slide is an example of an FVR and the information that needs to match the claim.

  • Check the FVR to confirm the receipt date shows the OASIS was accepted by iQIES before you submitted your claim. This date is shown on Page 1 of the report, in the “Completion Date/Time” field. Also ensure that the assessment has not been inactivated.
  • If the OASIS was submitted after the claim, resubmit the claim. If the claim is in the RTP file (T B9997), press F9.
  • If the assessment was inactivated, resubmit the assessment.
  • Check the Reason for Assessment (RFA) (OASIS Item M0100). It must be equal to 01, 03, 04, or 05.
  • If the claim matches an assessment that is for another reason, update the occurrence code 50 date on the claim to correspond to the M0090 date of the applicable assessment and resubmit the claim.
  • Check the occurrence code 50 and ensure that you are reporting the assessment completion date (Item M0090).
  • Check the claim you submitted with the OASIS to ensure the following items match.
  • CMS Certification Number (OASIS Item M0010) – This is your agency’s Medicare provider number, (often referred to as PTAN).
  • Medicare Beneficiary Identifier (MBI) (OASIS Item M0063) – Effective January 1, 2020, regardless of the dates of service, all claims must be submitted with the new MBI. If the OASIS was submitted with the Health Insurance Claim Number (HICN), the OASIS will need to be corrected.
  • Assessment Completion Date (OASIS Item M0090) – This is the date submitted on the claim with occurrence code 50.

If the claim and OASIS have correct and matching information

 

Final Validation Report (FVR) example

 

Reason Code: 32243
A home health billing transaction (Request for Anticipated Payment, final claim or adjustment) was submitted without a 0023 revenue code line OR a revenue code line for a visit was billed without charges

  • Ensure that all billing transactions submitted for services paid under the Home Health Prospective Payment System (HH PPS) include a 0023 revenue code line. See the screen print of FISS Page 02 below. A revenue code 0003 was entered on line 1 instead of a revenue code 0023.

  • Ensure that charges are entered for all revenue code lines reporting supplies or a visit. In the example of FISS Page 02 below, revenue code lines 6, 7, and 8 were billed without charges, resulting in the claim being returned with reason code 32243.
    • Reminder: You may need to press the F5 and F6 keys when reviewing revenue code information on FISS Page 02 in order to determine which line item dates of service are missing charges.

Reason Code 31018:

  • There is a span of more than 30 days between the “FROM” and “TO” date submitted on the claim.
  • Example 1: “FROM” date billed is March 15 and the “TO” date billed is April 14, which equals 31 days
  • Example 2: “FROM” date billed is March 15, and the “TO” date billed is May 13, which equals 60 days
  • There is less than 30 days between the “FROM” and “TO” date submitted, and a patient status code “30” appears on the claim.
  • Example: “FROM” date billed is March 15 and the “TO” date billed is April 11, which equals 28 days. Patient status code “30” indicates the beneficiary remains a patient of the HHA at the end of the period of care; therefore, the span between the “FROM” and “TO” dates cannot be less than 30 days.
  • Under the PDGM the unit of payment is a 30-day period of care.
  • Verify the “FROM” and “TO” dates submitted on home health claims to ensure there is never a span of more than 30 calendar days submitted on a final claim (type of bill 329)
  • Determine the 30th day of a period of care based on the “FROM” date.
  • If the span of days is less than 30 days, and the patient was discharged, enter the appropriate patient status code as of the “TO” date on the claim
  • This code is entered in the “STAT” field found on FISS claim page 01 or form locator 17 on the CMS-1450 form
  • If you are using a billing software that calculates the episode dates and you are receiving this error, address this issue with your software vendor.

 

Reason Code U5391:
Home health final claim submitted; however, a processed, matching RAP cannot be found.

  • Prior to submitting the final claim, access FISS Claim Inquiry option (Option 12) to determine if the RAP is in FISS status/location (S/LOC) P B9997
    • You should not submit the final claim for the episode unless the RAP is in this S/LOC
  • Review your DDE or your Medicare Remittance Advice timely to verify the RAP has completed processing
  • Submit the final claim timely according to regulations under the Home Health Prospective Payment System (HH PPS) and the Patient Driven Groupings Model (PDGM) based on the dates of service of the claim.
    • Under HH PPS, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the episode
    • Under PDGM for periods of care beginning January 1, 2020, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the 30-day period of care.
  • Prior to submitting the final claim, ensure the RAP has not auto-canceled

 

Reason Code U538I:

A home health RAP or claim overlaps an existing episode with a different provider number. This error most commonly occurs when a beneficiary elects to transfer from one HHA to another during a 60 day episode or 30-day period of care under the home health Patient Driven Groupings Model (PDGM) and the receiving HHA submits their initial episode RAP/claim without a condition code 47 to indicate a transfer between HHAs.

  • Prior to admission or submitting RAPs/claims to Medicare, check the beneficiary’s eligibility file to review established home health episodes for beneficiary, which may impact your dates of service.
  • If the beneficiary is transferring to your home health agency:
    • Follow the steps for appropriately completing beneficiary elected transfers

    • Get the information displayed for the other provider in their National Provider Identifier (NPI)

  • To indicate a beneficiary has transferred to your HHA, enter a condition code “47” in the first available COND CODES field (FL 18-28) on FISS page 01

 

 

Reason Code U538F:

A Request for Anticipated Payment (RAP) or final claim overlaps an existing period of care with the same provider number and the “FROM” date equals the period of care start date OR a visit date on a final claim falls within another period of care established by another home health agency (HHA) or the billing HHA.

HHAs receive this error most often when they submit a second RAP for a period of care where the final claim for the same period of care was previously submitted and rejected (FISS status/location (S/LOC) R B9997). Example: An HHA submits a RAP and final claim for a period of care from 06/25/YY to 07/24/YY. The final claim rejects to S/LOC R B9997. The HHA submits a second RAP for 06/25/YY – 06/25/YY, which is sent to RTP (T B9997) with reason code U538F.

Billing errors for this reason code may also occur when a home health agency submits a final claim and it contains a visit date (line item date of service – LIDOS) that overlaps another HHA’s period of care or the billing provider’s subsequent period of care. Example: ABC Home Care submits a final claim for 04/21/YY – 05/20/YY, which contains a LIDOS for 05/08/YY; however, XYZ Home Care has already established an episode from 05/05/YY to 06/03/YY, which is posted to Common Working File (CWF) for the beneficiary. ABC Home Care’s final claim is sent to RTP with reason code U538F because their 05/08/YY visit falls within XYZ Home Care’s 05/05/YY – 06/03/YY period of care.

HHAs may also receive this error when they submit a final claim with dates of service that overlap two separate episodes established by the HHA. This occurs when HHAs submit multiple RAPs during the same 60 day episode, which creates multiple episodes for the beneficiary on CWF.

  • Submit only one RAP and final claim for each period of care. If the final claim for the episode rejects, do not submit a second RAP. The final claim will need to be adjusted or resubmitted.
  • Prior to admission or submitting RAPs/claims to Medicare, check the beneficiary’s eligibility file to review established home health episodes, which may impact your dates of service.
  • If another HHA’s period of care overlaps your dates of service AND you are disputing their period of care, you must follow the instructions for resolving a transfer dispute
  • If another HHA’s period of care overlaps your dates of service AND there is NO dispute regarding the dates of service, remove the overlapping dates from your claim.
  • The only time HHAs should submit a second RAP during a period of care that they have established is when the beneficiary is discharged due to meeting the goals of the plan of care and is readmitted to the agency during that same 30-day period of care.

 

 

Reason Code 34982:

The home health claim (type of bill 32X – excluding 320 and 322) is being returned because occurrence code 50 is not present

Ensure that the occurrence code 50 is reported on all final claims with dates of service on or after January 1, 2020. Occurrence code 50 must be reported with the OASIS assessment completion dates (OASIS item MO090) for the start of care, resumption of care, recertification or other follow-up OASIS that occurred most recently before the claim “From” date.

Common rejections

  • overlapping claims
  • coverage ending
  • zip code entry to match the county code
  • patients that died before 60 day episode, episode adjustments

Problems

  • providers need to learn how to read their remits in their software

Challenges

  • keeping up with the changes of the Medicare
  • making sure the documentation from clinical match with the billing
  • getting orders signed & completed before the final needs to be billed & before the rap auto cancels