Home Health Blogger

Denial of Home Health Payments when OASIS is not Received

Posted by Peggy Mathews on Jan 2, 2017


Medicare Change Request (CR) 9585 directs Intermediaries to automate the denial of Home Health Care Billing Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met on MyHomecareBiz. Make sure that your HH billing software staff are aware of this change submission of an Outcome and Assessment Information Set (OASIS) assessment for all Home Health Billing Software (HH) episodes of care is a condition of payment.

If the OASIS is not found during medical review of an HH claim, the claim is denied. Original Medicare systems validate the HIPPS code submitted on an HH claim against the HIPPS code calculated by when the OASIS assessment is received in the Quality Information Evaluation System (QIES). If the codes do not match, the HIPPS code calculated from the OASIS assessment is used for payment. Currently, Medicare systems take no action on claims when the O4883994.jpgASIS assessment is not found.  Per the Code of Federal Regulations (CFR) at 42 CFR 484.210(e), (https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf) submission of an Outcome and Assessment Information Set (OASIS) assessment for all HH episodes of care is a condition of payment.

If the OASIS is not found during medical review of an HH claim, the claim is denied. Original Medicare systems validate the HIPPS code submitted on an HH claim against the HIPPS code calculated by when the OASIS assessment is received in the Quality Information Evaluation System (QIES). If the codes do not match, the HIPPS code calculated from the OASIS assessment is used for payment.

Currently, Medicare systems take no action on claims when the OASIS assessment is not foundPer the Code of Federal Regulations (CFR) at 42 CFR 484.210(e), (https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf) submission of an Outcome and Assessment Information Set (OASIS) assessment for all Home Health (HH) episodes of care is a condition of payment. If the OASIS is not found during medical review of an HH claim, the claim is denied. Original Medicare systems validate the HIPPS code submitted on an HH claim against the HIPPS code calculated by when the Download-Home-Health-2017-CMS-Final-RuleOASIS assessment is received in the Quality Information Evaluation System (QIES). If the codes do not match, the HIPPS code calculated from the OASIS assessment is used for payment. Currently, Medicare systems take no action on claims when the OASIS assessment is not found.

 

For more information on Medicare's Home Health Care Quality Indicators click here.

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