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July 28, 2017

Requesting an Appeal for No Matching OASIS Found

Change Request (CR) 9585 instructed Medicare contractors to automate the denial of home health claims when the requirement for submission of the Outcome and Assessment Information Set (OASIS) assessment has not been met. The OASIS, which is a condition of payment, is to be transmitted to the Quality Improvement Evaluation System (QIES) within 30 days of completion. If the OASIS assessment is not found in the QIES upon receipt of a final claim, and is past due, Medicare will deny the claim with reason code 37253.

Providers do have the right to appeal the denial. A request for a redetermination can be submitted by completing the CGS Medicare HHH Jurisdiction 15 Redetermination Request Form or through myCGS, the secure web portal. Refer to the HHH Redetermination Requests through myCGS job aid for additional information. The redetermination request must include verification of timely submission of the OASIS. This can either be verification through QIES or other forms of documentation showing timely OASIS submission. Note that it is not necessary to submit the full medical record when appealing the denial for reason code 37253.

For additional information, refer to the following resources:

  • MM9585External PDF – Denial of Home Health Payments When Required Patient Assessment Is Not Received
  • SE17009External PDF – Denial of Home Health Payments When Required Patient Assessment Is Not Received – Additional Information

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