Agencies submitting claims under a waiver authorized in response to recent hurricane and wildfire emergency events no longer will be at risk to have claims returned to provider (RTP’d) in error because of a failure to match the claim with a corresponding OASIS.
Change Request 10372 issued Jan. 5 makes a total of three edits around home health claims processing. The edits address problems arising from public health emergency waivers and matching claims to OASIS assessments.
HHS declared public health emergencies existed in several states in the wake of hurricanes and wildfires in 2017, and authorized a waiver that modified the OASIS transmission requirements for agencies serving patients and evacuees in the affected areas.
When submitting these claims, agencies are instructed to use the DR condition code to indicate Medicare payment is conditioned on the presence of a formal waiver.
But this code wasn’t recognized by existing Medicare systems, so claims “suspended to determine the appropriateness of condition code DR and then released for processing would be [RTP’d] in error unless the contractor takes additional manual actions,” according to CMS.
The change request adds a bypass for condition code DR so there won’t be a need for a manual workload, CMS says.
During research of other problems related to the claims-OASIS match, Medicare Administrative Contractors (MACs) reported claims with condition code 21 (billing for denial) were sent to the matching process unnecessarily.
It happened because the condition code 21 claims were submitted with the wrong Type of Bill (TOB). A new edit will ensure condition code 21 only may be reported on claims with TOB 0320, consistent with longstanding instructions in the Medicare Claims Processing Manual.
These are not the first updates to the OASIS match issue. In October 2017, CMS announced it would RTP any claims with no matching OASIS. Originally, the change resulted in automatic denials when a claim could not be matched with an OASIS assessment. (
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Some agencies encountered unanticipated denials even when the OASIS was submitted timely. MACs look to match the following OASIS items: Certification number (M0010), beneficiary Medicare number (M0063), assessment completion date (M0090) and reason for assessment (M0100), according to CMS.
The final edit under Change Request 10372 also deals with emergencies. One of the waivers allows MACs to extend the auto-cancellation date of requests for anticipated payment (RAPs) during emergencies. MACs were given a way to extend these dates.
The edit makes it possible for this process to be reusable and available for any future emergencies.