Increasing denials for claims submitted since 1 April 2017 are troubling home health agencies across the nation.
CMS now requires an automated match with the correlating home health payment start-of-episode (SOE) OASIS assessment before paying any home health claim submitted.
This process has some agency billers scratching their heads as seemingly correct claims bounce back as denied.
These denials have nothing to do with clinical auditing. The billing computer at each Medicare Administrative Contractor (MAC) is now programmed to verify specific data before payment. The absence of any required bit of information prompts a denial.
The automation first checks whether the SOC, ROC, or Recert OASIS assessment from the beginning of the up-to-60-day payment episode is due. This, for now, is 40 days past the M0090 date on the SOE OASIS assessment. CMS warns that eventually, the deadline will be 30 days past the M0090 date.
If the system identifies that a submitted claim matches a SOE OASIS assessment that was submitted and accepted timely or is not yet due, it pays the claim.
If not, the payment system automatically denies the claim based on Change Request 9585.
Specific OASIS items determine whether the claim matches the OASIS assessment. Before submitting the OASIS assessment and the final claim, make sure these OASIS items are correct:
- Home health agency (HHA) Certification Number (OASIS item M0010)
- Beneficiary Medicare Number (OASIS item M0063)
- Assessment Completion Date (OASIS item M0090
- Reason for Assessment (OASIS Item M0100) = 01, 03, or 04
Also, before billing the final claim, verify that the SOC, ROC, or Recert OASIS assessment that marks the start of the claim's payment episode finishes processing and that the Quality Information and Evaluating System (QIES) accepts it in the national database. The OASIS Agency Final Validation Report and the OASIS Submitter Final Validation Report that includes the SOE OASIS assessment confirms the assessment's receipt, the date of receipt, and any fatal or warning errors encountered.
For additional information, see: