Home Health & Hospice Week

Even appealable denials trigger a full medical review.

A simple technical glitch can cost home health agencies thousands upon thousands of dollars before they know it under the new OASIS matching edit, and the nearly universal inability to appeal denials can be crushing.

The edit that took effect April 1 denies claims when they don’t have a matching OASIS file in the QIES database and when the claim is filed more than 40 days after the OASIS completion data (M0090). Most of the denials occur because there is no OASIS in the system when the edit checks for it, and there’s simply no way to appeal a missing OASIS file, experts stress.

Nope: Simply submitting the OASIS with the appeal won’t work. The OASIS file must be in the database at the time the agency filed the claim.

And nope: Even when you believe you submitted the OASIS file, if it’s not in the database when the edit checked for it, your claim is entirely denied. “Please be aware that a notice of transmittal by facsimile is not evidence that the information has been accepted by the repository,” says HHH Medicare Administrative Contractor National Government Services in its job aid on the edit. “Please ensure it is in the repository.”

Yes: If you have a confirmation in the form of the OASIS Validation Report that the OASIS file was accepted and you receive a denial, then you have grounds for an appeal.

And yes: Another valid reason for an appeal is if the beneficiary’s Medicare number (M0063) is incorrect on the OASIS or claim. “For example, a patient has a Medicare number that includes her spouse’s

Social Security number and a letter on the end,” offers Melinda Gaboury with Healthcare Provider Solutions in a blog post. “During the time between the OASIS completion and submission and the transmission of the claims, the Medicare number changes due to the spouse’s death. This will create a denial of the claim and the agency will have to appeal.”

But an ability to appeal is not a pain-free solution. “The appeal is not just sending proof of the OASIS being transmitted, but the entire chart must be submitted for review … just as if you have received an Additional Development Request (ADR),” Gaboury warns. “Even if the appeal results in the approval of the OASIS transmission, there are going to be consequences of the ADR review for other documentation issues in the chart.”

How It Happens

Why do so many agencies think they have successfully submitted OASIS files to the QIES database? Because their submission software tells them the files have been successfully transmitted, Gaboury says.

You must check the official OASIS Validation Report for acceptance for each and every claim before submitting it, she stresses.