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Last Modified: 6/27/2020 Location: FL, PR, USVI Business: Part A

Avoiding RTP reason code 37096 FAQ

Q: We are receiving a return to provider (RTP) reason code 37096; what steps can we take to avoid this reason code?
Click here 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
Common errors:
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 external pdf file
Medicare Learning Network® (MLN®) MM7019 external pdf file
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