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Reason Code Search and Resolution

Disclaimer: This is not a complete listing of reason codes.

This Reason Code Search and Resolution tool has been designed to aid Medicare providers in reviewing reason codes and how to resolve the edit or use them for determining if other action is needed. You may search this database by reason code or keyword. All records matching your search criteria will be returned for your review. Or, if you wish, you may also view the entire listing of reason codes, their descriptions, resolutions, and additional billing information by clicking on the "Show all Reason Codes" option.

If no reason code displays, access the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) and select Option 17 “Reason Codes” from the Inquiry Menu to review the reason code description. For additional information refer to the Chapter 3: Inquiry MenuPDF of the FISS DDE Guide.

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Reason Code 37253

Description:

This reason code is assigned when there is no corresponding OASIS assessment found in Medicare's systems related to the claim.

Resolution:

Before submitting your claim review the OASIS Final Validation Report (FVR) to ensure the OASIS assessment was successfully accepted. Below is an example of an FVR and the information that needs to match the claim.
Screenshot

  • Check the FVR to confirm the receipt date shows the OASIS was accepted by iQIES before you submitted your claim. This date is shown on Page 1 of the report, in the "Completion Date/Time" field. Also ensure that the assessment has not been inactivated.
  • If the OASIS was submitted after the claim, resubmit the claim. If the claim is in the RTP file (T B9997), press F9.
  • If the assessment was inactivated, resubmit the assessment.
  • Check the Reason for Assessment (RFA) (OASIS Item M0100). It must be equal to 01, 03, 04, or 05.
  • If the claim matches an assessment that is for another reason, update the occurrence code 50 date on the claim to correspond to the M0090 date of the applicable assessment and resubmit the claim.
  • Check the occurrence code 50 and ensure that you are reporting the assessment completion date (Item M0090).
  • Check the claim you submitted with the OASIS to ensure the following items match.
  • CMS Certification Number (OASIS Item M0010) – This is your agency's Medicare provider number, (often referred to as PTAN).
  • Medicare Beneficiary Identifier (MBI) (OASIS Item M0063) – Effective January 1, 2020, regardless of the dates of service, all claims must be submitted with the new MBI. If the OASIS was submitted with the Health Insurance Claim Number (HICN), the OASIS will need to be corrected.
    • Changes to a beneficiary's MBI may occur. Verify the MBI using the MBI look-up tool via myCGS. Refer to the myCGS MBI Look-up Tool for details on how to verify the MBI. If the MBI has changed, update Item M0063 on the OASIS and resubmit the claim.
  • Assessment Completion Date (OASIS Item M0090) – This is the date submitted on the claim with occurrence code 50.

If the claim and OASIS have correct and matching information, contact the Provider Contact Center (PCC) at 1.877.299.4500 (Option 1).

If there is no error and it is determined the claim did not meet the condition of payment, submit a claim for denial using the following coding elements:

  • Type of bill 0320, which indicates the expectation of a full denial
  • Occurrence Span Code 77 with span dates matching the From/Through dates of the claim to indicate acknowledgement of liability for the billing period.
  • Condition Code D2 indicating the change in billing the HIPPS code to non-covered.
  • DO NOT use condition code 21.

References:

Updated: 04.07.2020


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