Correcting Reason Code 37253

To ensure home health claim information aligns with OASIS data, the iQIES OASIS claim data match is essential. If no matching assessment is found in iQIES when a claim is submitted, it will be returned with reason code 37253. Use the following checklist to verify and correct this error:

1. Review the FVR to confirm the OASIS receipt date is before the claim submission.
   • If the OASIS was submitted after the claim, resubmit the claim.
   • If the assessment was inactivated, resubmit the assessment.
2. Ensure the RFA (OASIS Item M0100) equals 01, 03, 04, or 05.
3. Include occurrence code 50 on any PDGM claims, with the assessment completion date (item M0090). They must match.
   • If missing or incorrect, update and resubmit the claim.

4. Verify the following items match on both the claim and FVR:
   • Provider CMS Certification Number (PTAN) M0010   
   • Beneficiary Medicare Number (MBI) M0063. If item M0063 contains '^', update it to reflect the correct MBI and resubmit the claim.
   • Assessment Completion Date M0090 must match occurrence code 50.

Note: Changes to a beneficiary’s MBI can affect the match. If an MBI change is identified, update item M0063 on the OASIS and resubmit the claim.

Please note: it is not appropriate to send an insurance denial (with condition code 21) when a claim is assigned the 37253 reason code. Submitting the claim with condition code 21 would result in inappropriate beneficiary liability. You must follow the steps outlined above to correct the RTP for the claim to process correctly.

Please refer to MLN Matters® SE20010: Ensure Required Patient Assessment Information for Home Health Claims for more information.

Posted 11/14/2024