Home Health

RAP issue will require new step from agencies to avoid claim denial

Agencies are receiving new guidance from Medicare Administrative Contractors (MACs) to address one of several issues that have caused erroneously rejected RAPs and claims since the start of the year.

For second period RAPs that have been submitted early, as allowed under the new RAP rules, you will want to make sure the 0023 line date on your final claim matches the 0023 line date you used on the RAP, according to guidance from Palmetto GBA.

Under new rules for the no-pay RAPS, beginning Jan. 1, agencies can submit the RAP for the first and second 30-day periods of care at the same time (MM11855). Earlier this month, this became an issue as claims for some second periods were being denied with reason code U5391 or 38107.

In a message to agencies Wednesday, Palmetto GBA explained the issue is due to guidance from CMS that the second RAPs should use the first day of the period of care as the service date on the 0023 line.  

The problem is CMS didn’t address claims billing rules (Chapter 10, Section 40.2) that require the 0023 line instead use the date of the first visit during the second 30-day period. So, when these claims were arriving with a date on that line that was different from what was provided on the RAP, it was causing the denial.

Palmetto GBA is instructing its agencies to use the date used on the RAP, the first day of the period of care, when filing these claims so that the RAP and the claim match.

Melinda Gaboury, COS-C, CEO of Healthcare Provider Solutions Inc. of Nashville, Tenn., offered this example to Home Health Line:

  • RAP 0023 line date: 2/4/2021
  • Final claim 0023 line date: 2/4/2021
  • First visit in visit details: 2/8/2021