Last Modified: 6/27/2020
Location: FL, PR, USVI
Business: Part A
Q: We are receiving a return to provider (RTP) reason code 37096; what steps can we take to avoid this reason code?
for a description associated with the Medicare Part A reason code(s). Simply enter a valid reason code into the box and click the submit button.
A: You are receiving this reason code when no assessment record is on file for this Inpatient Rehabilitation Facility (IRF) claim.
• The IRF patient assessment instrument (IRF-PAI):
• Prior to submission of your IRF claim to the Fiscal Intermediary Shared System (FISS) for reimbursement, you must have submitted an IRF-PAI for the patient;
• IRF-PAI must have been accepted and completed processing at the Centers for Medicare & Medicaid Services (CMS) National Assessment Collection Database;
• Review the IRF-PAI validation report to verify it has been accepted in the assessment database
• The IRF must ensure the IRF-PAI data matches the information on the associated claim in FISS
• Medicare Beneficiary Identifier (MBI) (IRF-PAI item 2);
• Beneficiary date of birth (IRF-PAI item 6);
• Provider CCN (IRF-PAI item IB);
• Claim statement covers through dates (IRF-PAI item 40); and
• Claim admission date (IRF-PAI item 12)
• Validate the occurrence code (OC) 50 assessment date on the claim matches the accepted validation report transmission date on the PAI
• IRF is submitting their claim to Medicare prior to the IRF-PAI being completely processed at the National Assessment Collection Database
• Providers may want to add an additional claim hold day(s) on their claim submission to allow IRF-PAI to complete processing
• MBI submitted on the IRF-PAI does not match the MBI in Fiscal Intermediary Shared System (FISS)
• If info does not match, an assessment will not be linked, and the claim will RTP
• IRF may need to correct the IRF-PAI and/or correct the claim
• The discharge date on the IRF-PAI does not match the information in FISS
For additional resource information:
Medicare Learning Network® (MLN®), Special Edition Article SE1342
Medicare Learning Network® (MLN®) MM7019
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