As of April 1, 2017, Medicare began automatically denying claims with missing patient assessment data in the OASIS. Agencies are scratching their heads over the new denials. With some, they just plain messed up. The OASIS was not transmitted before the final claim for the episode was transmitted. With some, OASIS was submitted in time, but certain data was wrong or missing. In some cases, however, it is difficult to figure out what went wrong.
The CoPs require that OASIS be transmitted within 30 days of completion (M0090 date). If the OASIS assessment is not found and the receipt date of the claim is more than 30 days after the assessment completion date on the claims, Medicare will deny the claim. Initial implementation allows for 40 days.
The system will check to see whether the OASIS has been completed and accepted into the QIES database (that’s where the OASIS goes, hopefully, when transmitted). The claim will be denied if the assessment is missing AND past due. Medicare will have the Group Code of CO and Claim Adjustment Reason Code 272 on the denial.
Any errors encountered during submission should be evaluated so that it doesn’t happen again.
These four M0 items are checked by the system, so ensure they are complete. These items will be used to match claims and assessments:
- HHA CMS Certification Number (OASIS item M0010)
- Beneficiary Medicare Number (OASIS item M0063)
- Assessment Completion Date (OASIS item M0090)
- Reason for Assessment (OASIS item M0100) equals to 01, 03, or 04 (Start of Care, Resumption of Care and Recertification).
Beneficiary Medicare Number (OASIS item M0063)
Assessment Completion Date (OASIS item M0090)
Reason for Assessment (OASIS item M0100) equals to 01, 03, or 04 (Start of Care, Resumption of Care and Recertification).
The Medicare number is a common reason for denial. NAHC is working with CMS to encourage the use of some other identifier since the letter changes based on marital status.
Other problems include blanks in the OASIS data, wrong assessments, and untimely assessments. Selman-Holman been evaluating the different reasons for denials to determine the best course of action.
First action: These denials can be appealed. The first step is to check the OASIS Agency Final Validation Report and OASIS Submitter Final Validation Report to confirm that the assessment was transmitted AND accepted. If it is not there, figure out what went wrong.
Second action: Prior to submitting claims, check the OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report for the OASIS that goes with the claim. Do not transmit a final claim for the episode if the OASIS has not been accepted. You can still fix errors after the 40 days. Accuracy is important. Denials happen when missing AND past due.
Best action: Contact the Selman-Holman’s Denials Management Team for any assistance with ADRs, appeals and other audits. Call us at 214-550-1477.