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Claim Page 05 – Entering a RAP or Claim

Claim Page 05 (Map 1715) contains the Home Health Prospective Payment System (HH PPS) Claim-OASIS Matching Key code. Under the home health Patient Driven Groupings Model (PDGM), claims with the "From" date on or after January 1, 2020, do not require the OASIS Matching Key code. The TREAT.AUTH.CODE field below is left blank. Once the claim is processed, insured person(s) information will display when Medicare is the secondary payer. No insured information should be entered on FISS Claim Page 05. To submit Medicare Secondary Payer (MSP) claims and adjustments via the American National Standard Institute (ANSI) ASC X12N 837 5010 format refer to the Medicare Secondary Payer (MSP) Web page or the Medicare Secondary Payer (MSP) Online Tool.

example

Key:

  • RED = Required field
  • BLUE = Optional field
  • GREEN = Conditional field, depended on the type of claim
  • PURPLE = System generated field
  • BLACK = Not required field

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Field Descriptions for Claim Page 05 – Map 1715

The MID, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.

Field Name Description

TREAT. AUTH. CODE
Required

Not required on claims with the "From" date on or after January 1, 2020.

Treatment Authorization Code.

Key the billing transaction's 18 position Claim-OASIS Matching Key output from the Grouper softwareExternal Websiteon all RAPs and HH PPS claims.

This code contains the start of care date, the date the assessment was completed, the reason for the assessment, whether the episode was "early" or "late" and the clinical and functional domain points under the four equation model of the HH PPS case mix system. The format of the code is made up of numeric and alpha character calculated by the Grouper software: 99XX99XX99XXXXXXXX (e.g., 12JK12AA41GBMDCDLG)

If Medicare is the primary payer, the Claim-OASIS matching key code must be entered in the first TREAT. AUTH. CODE field immediately under Line C. If Medicare is the secondary payer, enter the Claim-OASIS matching key in the second TREAT. AUTH. CODE field. If Medicare is the tertiary payer, the Claim-OASIS matching key must be typed in the third TREAT. AUTH. CODE field.

Additional FISS Claim Pages

Updated: 12.17.19

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