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January 22. 2020

How Can You Reduce Errors for Reason Codes (RC) 38107?

Home health agencies (HHAs) are reminded of the following Medicare billing guideline requiring that the final claim have a matching Request for Anticipated Payment (RAP). The following explains what claim elements must match in order for the Fiscal Intermediary Standard System (FISS) to find the RAP that matches the final claim.

NOTE: This requirement does not change with the implementation of the home health Patient-Driven Groupings Model (PDGM).

Reason code 38107 has historically been the top claim submission error for home health providers.  When FISS is unable to find a matching RAP for the final claim, reason code 38107 will apply to the final claim and will be sent to the return to provider (RTP) file.  CGS data shows the top 100 providers had 10,527 claims that received reason code 38107 and were sent to the RTP file from October – December 2019.  The following chart shows data for the J15 primary states.

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Please share this information with your billing staff to reduce the number of your claims that receive the 38107 claim submission error. 

Matching Claim Elements
When a final claim is submitted, FISS will search for a matching RAP using the following fields. 

FISS Field Name

FISS Page

UB-04 Form Locator (FL)

Data Entered

NPI

1

60

National Provider Identifier (NPI) of the billing provider

STMT DATES FROM

1

6

Start of care (SOC) episodes only:  Date of first Medicare billable visit in the episode/period of care

Recertification (subsequent) episodes:  First calendar day of the episode/period of care

ADMIT DATE

1

12

Date of first Medicare billable visit in the beneficiary’s initial episode/period of care with the primary HHA

HCPC

2

44

0023 revenue code line:  Health Insurance Prospective Payment System (HIPPS) code.  FISS compares the first four positions of the HIPPS code between the RAP and final claim for the same episode of care

SERV DATE

2

45

0023 revenue code line:  First Medicare billable visit in the episode

Examples of FISS page 1 and page 2 are shown below with the matching fields indicated.

Screen Shot

Refer to the following resources for assistance with avoiding/reducing the number of your claims that receive reason code 38107.

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