Home Health & Hospice Week

It’s worth it to check HICNs before claim submission.

Many home health agencies are learning the hard way that they should not underestimate the OASIS matching edit. Various factors ranging from systemic breakdowns to fleeting technical glitches can result in big-dollar denials.

Heed this expert advice to keep these nearly unappealable denials from impacting your bottom line:

1. Submit on time, every time. “Ensure that the OASIS is transmitted within the specified time requirement (30 days from the date the OASIS is completed),” urges HHH Medicare Administrative Contractor Palmetto GBA in an article recently posted to its website, “Understanding Claim Denials with Reason Code 37253.” The OASIS matching edit actually gives agencies a bit of leeway on the timeframe — it checks for the OASIS once the claim is 40 days out from the OASIS completion date instead of 30. The Centers for Medicare & Medicaid Services has indicated it may tighten up that timeframe later.

“There is no reason not to send the OASIS data forward,” chides Lynn Olson of billing company Astrid Medical Services in Corpus Christi, Texas.

2. Check the HICN before billing. One of the items used to identify a matching OASIS file for a claim is the Medicare beneficiary number (M0063). HHAs have been running into problems with having the wrong numbers on the OASIS file, so then the edit can’t match the OASIS to the claim.

Palmetto offers this example in its article: “Patient’s Health Insurance Claim (HIC) number submitted on the OASIS had a ‘B’ on the suffix, but the beneficiary’s/patient’s Medicare records reflected that the HIC number changed the suffix to a ‘D.’”

The MAC continues, “When a patient’s Medicare records reflect a corrected HIC number, the Fiscal Intermediary Standard System (FISS) will automatically cross-reference the claim to the correct HIC number and process the claim accordingly. The QIES will process the OASIS with the HIC number that was initially transmitted.” The mismatch causes a denial.

To avoid this problem, and the full medical review of the claim that comes with an appeal of the error, “verify that the patient’s Medicare HIC Number submitted on the OASIS matches the HIC Number that was submitted and/or processed on the claim,” Palmetto advises. “This can be done by reviewing the remittance advice and/or checking claim page 1 of the Direct Data Entry (DDE) system.”

In fact, you should “validate a beneficiary/patient’s Medicare eligibility records periodically,” Palmetto recommends. “Changes to a HIC will be reflected on page 1 of HIQA or HIQH in the ‘CORRECT’ field.”

The thought of checking all those HICNs may sound “impossible,” Gaboury acknowledges, “but it is really not. For those with software systems that run the eligibility checks for the agency, you simply check for Medicare number updates prior to transmitting final claims,” she advises.

Shortcut: “Technically, the change of the Medicare number is typically with female patients and it might prove sufficient to only check that gender,” Gaboury adds.

3. Verify with the OASIS Validation Report. The silver bullet for defeating OASIS matching-edit denials is to check the OASIS Validation Report for each and every OASIS file submitted. The OASIS Agency Final Validation Report or the OASIS Submitter Final Validation Report “will provide information that confirms the assessment’s receipt, the date of receipt, and any fatal or warning errors encountered,” MAC CGS explains in a recent article.

4. Know which errors matter. “The OASIS will not be accepted if there are errors, which will be identified on the validation report,” Palmetto warns on its website. But not every error will mean the file isn’t accepted. “There may … be warning messages received on the validation report (e.g., a late submission may generate a warning that the OASIS was accepted but it was submitted to the repository more than 30 days after completion date)” but the file is still accepted, Palmetto explains. Remember, a late submission won’t trigger the denial unless the OASIS file is missing when the claim is submitted. If you submit the OASIS late, but it is in the database when you submit the final claim, you won’t receive a denial.

Bottom line: Check each file to be sure, and keep documentation of the report to furnish in case of an erroneous denial.

5. Appeal when warranted. For most denials, there’s no grounds for appeal because the OASIS file wasn’t in the QIES database. In Gaboury’s experience so far, the only appealable denials issued were when the HICN numbers mismatched. For the other denials, none of the OASIS files were actually in the database when agencies thought they were.

When you do find a HICN mismatch, or if you have proof via the validation report that the OASIS was in fact in the QIES database, submit this information with your appeal, Palmetto directs:

• A copy of the OASIS transmission/validation report;
• A hardcopy of the OASIS, which Palmetto says is “recommended” only. “The submission of a hardcopy OASIS is for verification of the data transmitted only and does not allow for a reversal of the denial,” Palmetto emphasizes;
• Medical documentation to support the medical necessity of the services rendered to include a copy of the initial Plan of Care (POC) and Face-to-Face (F2F) Encounter documentation. “Reason code 37253 is an automated denial, which results in a full review of the claim and all supporting documentation must be available to determine if payment can be made on the claim,” Palmetto explains.

The last point is important, stresses the National Government Services representative. Providers must “provide sufficient documentation to support medical necessity,” the rep tells Eli.