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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 37402

Description:

A hospice claim was submitted, but the previous claim is not found OR there is a gap between the “TO” date of the previous claim and the “FROM” date on the next claim.

Resolution:

Hospice claims must be submitted sequentially. This means that January's claim, for example, must be submitted before February's claim can be submitted.

Check the FISS Claim Inquiry Option (Option 12) to determine if the prior claim was submitted.

  • Example below: No prior claim in FISS

    37402

If prior claim was submitted, ensure it is in a "P", "D", or "R" status code before submitting the next claim.

  • Example below: Prior claim in "T" status; not "P", "D", or "R" as required.

    37402

Hospice claims must also be submitted consecutively. This means that there cannot be any skip in dates between the prior claim's "TO" date, and the next month's claim's "FROM" date; AND

Verify there is no gap between the "TO" date on the previous claim and the "FROM" date on the next claim.

  • Example below: Gap in dates between prior claim's "TO" date (0429YY) and next claim's "From" date (0501YY).

    37402

In addition, Hospices are required to bill claims monthly (see Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 11, §90). This means providers should bill only one claim per month, for each patient. The "To" date on the claim must be the last calendar day of the month, unless the patient died, was discharged or revoked hospice during the month.

In addition, hospice claims must conform to a calendar month (Jan 1 - Jan 31). Claims that span two months (ex. Jan 1-Feb 1) will be sent to the RTP file for you to correct.

Note: You must correct the claims out of Return to Provider (RTP) file sequentially. For example if the January claim is in RTP because of an invalid HCPC code, and the February claim was submitted, the February claim would go to RTP because no prior claim was found. You must first correct the January claim. Once the January claim is corrected and moves to a suspended status/location, the February claim can be F9ed out of RTP.

Additional resources:


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