CMS Pub. 100-04, ch. 3, § 140.3.1.1

Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI)

(Rev. 11075; Issued: 10-28-21; Effective: 12-01-21; Implementation: 12-01-21)

The following outcomes are possible when a claim does not match the IRF-PAI

HIPPS:

o A matching assessment is found. The claim HIPPS code does not match the

IRF-PAI HIPPS code, but the transmission date matches causing the

claims processing system to use the assessment HIPPS code documented in

iQIES for claims processing purposes;

o A matching assessment is found. The claim HIPPS code does not match

IRF-PAI HIPPS code, and the

transmission date is different causing the claims processing system to use

the assessment HIPPS code and date documented in iQIES for claims

processing purposes;

o A matching assessment is not found. This causes the claim to Return to

Provider (RTP) with Reason Code 37096.

IRFs should be sure to have an IRF-PAI that has completed processing at iQIES

before submitting an IRF claim to the Medicare Administrative Contractor. The

IRF can verify this by reviewing their IRF-PAI validation report.

If an IRF has inadvertently submitted their claim prior to the corresponding IRF-PAI being accepted in iQIES and the claim has RTP’d with Reason Code 37096,

simply resubmit the claim once the IRF-PAI has completed processing. This will

require communication between the provider’s billing office and their clinical staff

that submits their IRF-PAI.

If a claim is returned because Medicare systems do not find the matching

assessment, there is no need to call the QIES Technical Support Office (QTSO)

help desk for such billing issues.

If a provider has submitted an IRF-PAI prior to submission of the claim with

information that is different from the claim submission for any of the following

information:

o Medicare Beneficiary Identifier (IRF-PAI item 2);

o Beneficiary date of birth (IRF-PAI item 6);

o Provider CCN (IRF-PAI item 1B);

o Claim statement covers through dates (IRF-PAI item 40); and

o Claim admission date (IRF-PAI item 12).

The claim or the IRF-PAI should be corrected (depending on which item had the

error) and then the claim resubmitted. If the claim is resubmitted without

correcting the appropriate information, the claim will be returned to the provider

again.

In most cases the claim is being submitted one (1) day prior to the finalization of

the IRF-PAI. IRFs may want to add an additional claim hold day(s) on their claim

submission to allow IRF-PAI completing processing and to avoid claims being

RTP’d with Reason Code 37096.