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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 U5391

Description:

Home health final claim submitted; however, a processed, matching RAP cannot be found.

Resolution:

  • Prior to submitting the final claim, access FISS Claim Inquiry option (Option 12) to determine if the RAP is in FISS status/location (S/LOC) P B9997
    • You should not submit the final claim for the episode unless the RAP is in this S/LOC
  • Review your Medicare Remittance Advice timely to verify the RAP has completed processing
  • Submit the final claim timely according to regulations under the Home Health Prospective Payment System (HH PPS) and the Patient Driven Groupings Model (PDGM) based on the dates of service of the claim.
    • Under HH PPS, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the episode
    • Under PDGM for periods of care beginning January 1, 2020, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the 30-day period of care.
  • Prior to submitting the final claim, ensure the RAP has not auto-canceled
    • Step 1: Access FISS Inquiry Option 12
    • Step 2: Enter your HHA's National Provider Identifier in the NPI field
    • Step 3: Enter the beneficiary's Medicare number in the MID field
    • Step 4: Enter P B9997 in the S/LOC field
    • Step 5: Enter 328 in the TOB field
    • Step 6: Enter your episode's start date in the FROM date field
    • Step 7: Press Enter
    • FISS will return a listing of billing transactions that meet the criteria entered
    • If a 328 type of bill is displayed, tab down to it and key an "S" in the SEL field
      • Press Enter
      • Press your F8 key to page forward to FISS Page 03
      • Review the information in the ADJUSTMENT REASON CODE field at the bottom of the screen
      • If the letters NF appear in this field, FISS auto-canceled your RAP because the final claim was not received timely
      • If your RAP auto-canceled, re-bill the RAP and wait for it to process (P B9997)
      • Submit the final claim for the episode
    • If FISS does not return a 328 TOB, press your F3 button and follow Steps 1 through 7
      • If FISS still does not return a 328 TOB, then your RAP did not auto-cancel
      • Submit the final claim for the episode
  • Prior to submitting the final claim, ensure that the key information, listed below, for the episode's RAP and claim matches.
    • Provider number/identifier of the billing home health agency (FL 56)
    • "FROM" date of the episode (FL 6)
    • Date of admission (FL 12)
    • First four positions of the Health Insurance Prospective Payment System (HIPPS) code (FL 44)
      • If the fifth position of the HIPPS code needs to change based on the provision of non-routine supplies, your HHA should ensure that the supply severity level between the RAP and final claim for the same episode of care does not change.
    • Date of service billed with the HIPPS code (FL 45)

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