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Top Claim Submission Errors for Home Health Providers: Error U538F

Reason for error: A Request for Anticipated Payment (RAP) or final claim overlaps an existing episode with the same provider number and the "FROM" date equals the episode's start date OR a visit date on a final claim falls within another episode established by another home health agency (HHA) or the billing HHA.

HHAs receive this error most often when they submit a second RAP for an episode where the final claim for the same episode was previously submitted and rejected (FISS status/location (S/LOC) R B9997). Example: An HHA submits a RAP and final claim for an episode from 06/25/YY to 08/23/YY. The final claim rejects to S/LOC R B9997. The HHA submits a second RAP for 06/25/YY – 06/25/YY, which is sent to RTP (T B9997) with reason code U538F.

Billing errors for this reason code may also occur when a home health agency submits a final claim and it contains a visit date (line item date of service – LIDOS) that overlaps another HHA's episode or the billing provider's subsequent episode. Example: ABC Home Care submits a final claim for episode 04/21/YY – 06/19/YY, which contains a LIDOS for 06/08/YY; however, XYZ Home Care has already established an episode from 05/30/YY to 07/28/YY, which is posted to Common Working File (CWF) for the beneficiary. ABC Home Care's final claim is sent to RTP with reason code U538F because their 06/08/YY visit falls within XYZ Home Care's 05/30/YY – 07/28/YY episode.

HHAs may also receive this error when they submit a final claim with dates of service that overlap two separate episodes established by the HHA. This occurs when HHAs submit multiple RAPs during the same 60 day episode, which creates multiple episodes for the beneficiary on CWF.

Claim processing result: Return to Provider (RTP)

How to prevent/resolve:

  • Submit only one RAP and final claim for each episode of care. If the final claim for the episode rejects, do not submit a second RAP. The final claim will need to be adjusted or resubmitted. See the Resolving Rejected Home Health Claims Caused by Billing Errors Web page for assistance in determining whether to adjust or resubmit a rejected home health final claim.
  • Prior to admission or submitting RAPs/claims to Medicare, check the beneficiary's eligibility file to review established home health episodes, which may impact your dates of service.
    • See the CGS Checking Beneficiary Eligibility web page for more information about the systems available to providers to check Medicare beneficiary eligibility information.
  • If another HHA's episode overlaps your dates of service AND you are disputing their episode, you must follow the instructions for resolving a transfer dispute prior to contacting CGS for assistance. Also review the information regarding beneficiary elected home health transfers.
  • If another HHA's episode overlaps your dates of service AND there is NO dispute regarding the dates of service, remove the overlapping dates from your claim. Instructions for deleting revenue lines are accessible in Chapter Five - Claims CorrectionPDFof the Fiscal Intermediary Standard System (FISS) Guide.
  • The only time HHAs should submit a second RAP during an episode that they have established is when the beneficiary is discharged due to meeting the goals of the plan of care and is readmitted to the agency during that same 60-day episode. More information on this topic is available in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 10.1.5, 10.1.14 and 30.9PDF). For assistance in correcting home health episodes posted to the CWF, see the Correcting Home Health Episode Information Posted to the Common Working File (CWF) Web page.

Additional Resources

Updated: 10.31.18

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