Agencies have begun receiving denials stemming from a requirement that took effect in April. In many cases, those providers are surprised by what’s triggering the denials.
 
Providers knew Change Request 9585 would lead to deni­als if no OASIS assessment was in the system and it had been more than 40 days since the assessment was done. But many agencies didn’t anticipate Medicare Administrative Contractors (MACs) would deny claims with reason 37253 if the MACs couldn’t find certain information that matches on the assessment and final claims.
 
During this review, MACs look for the following OASIS items: Certification number (M0010), beneficiary Medicare number (M0063), assessment completion date (M0090) and reason for assessment (M0100), according to CMS.
 
A final claim also is automatically denied under Change Request 9585 if both of the following conditions exist: The OASIS assessment is not in the Quality Improvement and Evaluation System (QIES) and it has been more than 30 days since the assessment was completed. For an undetermined amount of time, CMS is allowing a little extra leeway, extending the deadline to 40 days, according to the change request.
 
This change, effective April 1, was meant to ensure an OASIS assessment was submitted before the final claim. A number of agencies, however, have experienced automatic denials with reason code 37253 even when the OASIS assessment was properly submitted prior to the final claim.
 
One of the common issues is with matching the Medicare beneficiary number, according to CMS.
 
Agencies should use the most recent Medicare beneficiary number they know of on both the OASIS and the claim to avoid a denial, according to CMS. Agencies can also avoid a denial in this situation by submitting a corrected OASIS with the new Medicare number before submitting a final claim; this will ensure the information matches, according to MAC Palmetto GBA.
 
Find out more about this issue in Home Health Line.