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ELECTRONIC CLAIMS Health Insurance Portability and Accountability Act's (HIPAA) Administrative Simplification
Compliance Act (ASCA) requirement of electronic billing applies ONLY to Medicare
claims.
Further Health Care providers should know know
that though a client healthcare provider may have electronically transmitted a claim to a
clearing house, the clearing house may not have electronic claims connection with the
insurer. So the claim is submitted as a paper claim by the clearing house. Clearing houses add
charges for paper claims.
Medicare (ASCA) requires certain providers
bill electronically using certain electronic claims protocol and technology.
Medicare (ASCA) requires healthcare institutions with 25 or more full-time employees and
other healthcare providers with 10 or more full-time employees, who on the average bill a Medicare fiscal agent or
carrier more than 10 times a month, 120 times/year, do so using the foregoing technology and copyrighted protocol. The
protocol is copyrighted by the Washington Publishing Co. which charges a copyright
license fee. The computer technology is known as Telnet and was popular in the
early 1980's. On the internet both Yahoo.com and Google.com have information on
Telnet.
For a law to be enforceable it must withstand
court challenges. Neither so far have been challenged. Questions do exist as to HIPAA and
ASCA conflicting with the United States Constitution provisions for freedom of speech,
trial by jury and freedom from discrimination.
The following is copied from CMS document
MM2966.PDF published 2003 on the World Wide Internet at cms.gov under the title
"Explanation of the Mandated Electronic Billing Requirement ...", and refers to
the Administrative Simplification Compliance Act (ASCA), a part of the Health Insurance
Portability and Accountability Act (HIPAA). Yahoo.com
publishes information on MM2966.
Related Change Request (CR) #: 2966 Medlearn Matters Number: MM2966
Related CR Release Date: December 19, 2003
Related CR Transmittal #: R44CP
Effective Date: October 16, 2003
Implementation Date: January 20, 2004
New Instructions for the Mandatory Electronic Submission of Medicare Claims
Providers Affected
All Medicare providers (except small providers). See below for more information on small
providers.
Provider Action Needed
STOP – Impact to You
Unless you qualify as a small provider, your initial claims to Medicare must be submitted
electronically as of October 16, 2003, or Medicare may not cover them.
CAUTION – What You Need to Know
The Administrative Simplification standards of the Health Insurance Portability and
Accountability Act (HIPAA) and the Administrative Simplification Compliance Act (ASCA)
impact how your claims must be submitted to Medicare. This article provides important
highlights for you.
GO – What You Need to Do
You should make sure that your billing staffs are aware of these requirements tosubmit
claims to Medicare electronically. Additionally, you should make sure that your process of
electronic submission is HIPAA compliant. The law and regulation permit a number of
exceptions to the electronic billing requirement. Although electronic submission is
encouraged, Medicare will continue to accept paper claims when any of the following apply:
1. Small providers - To qualify, a provider required to submit claims to Medicare Intermediaries
must have fewer than 25 full-time equivalent employees
(FTEs) and a physician, practitioner, or supplier that bills
a Medicare carrier must have fewer than 10 FTEs;
2. Provider is a dentist;
3. Provider is participating in a Medicare demonstration project when paper claim filing
is required by that demonstration project due to the inability of the applicable
implementation guide adopted under HIPAA to report data essential to the demonstration;
4. Provider that conducts mass immunizations, such as flu injections, for which the
provider was previously allowed to submit paper roster bills;
5. Providers that submit claims when more than one payer is responsible for payment prior
to Medicare payment; 6. Those few claims that may be submitted by beneficiaries;
7. Providers that only furnish services outside the United States;
8. Providers experiencing a disruption in their electricity or communication connection
that is outside of their control;
9. Providers that can establish that an "unusual circumstance" exists that
precludes submission of claims electronically;
10. Providers that are not "small" providers based on FTEs (see below), but
submit an average of fewer than 10 Medicare claims per month (not more than 120 claims per
year); and
11. Non-Medicare Managed Care Organizations that are able to bill Medicare for copayments
may continue to submit those claims on paper.Understanding these rules and complying with
them will assure continued prompt payment of Medicare claims.
BACKGROUND
Section 3 of the Administrative Simplification Compliance Act, Pub. Law 107-105
(ASCA), and the
implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement
under Medicare (except those from small providers) be submitted electronically as of
October 16, 2003, with limited exceptions
Based on this law and the implementing regulation, Medicare will not cover claims
submitted on paper that do not meet the limited exception criteria, briefly described
below. Claims denied for this reason will contain claim adjustment reason code 96
(Non-covered charge(s)) and remark code M117 (Not covered unless submitted via electronic
claim.) Enforcement of this policy will be conducted on a post-payment basis and will
entail targeted investigation of providers that appear to be submitting extraordinary
numbers of paper claims. If an investigation establishes that a provider improperly
submitted paper claims, the provider will be notified that Medicare will deny any paper
claims submitted after a date certain (allowing a reasonable period for implementation of
necessary provider changes)
.
Additional INFORMATION
Initial Claims
This requirement pertains to initial claims. Initial claims are those claims you
submit to a Medicare fee-forservice carrier, DMERC, or intermediary
for the first time, including previously rejected claims that you resubmit, claims with
paper attachments, demand bills, claims where Medicare is secondary and there is only one
primary payer, and nonpayment claims. Initial claims do not include adjustments that you
submit to intermediaries on claims that you have preciously submitted, or appeal
requests.Small Providers
This requirement pertains to all Medicare providers except "small providers."
Providers that qualify as "small" automatically qualify for waiver of the
requirement that their claims be submitted to Medicare electronically. A small provider is
defined at 42 CFR section 424.32(d) (1) (vii) to mean:
A. A provider of services (as that term is defined in section 1861(u) of the Social
Security Act) with fewer than 25 FTEs; or B. A physician, practitioner, facility or
supplier that is not otherwise a provider under section 1861(u) with fewer than 10 FTEs.
To simplify implementation, Medicare will consider as "small":
1) all providers that have fewer than 25 FTEs and that are required to bill a Medicare
intermediary; and
2) all physicians, practitioners, facilities, or suppliers with fewer than 10 FTEs and
that are required to bill a Medicare carrier or DMERC.
If you are a small provider, CMS encourages you to submit your claims to Medicare
electronically, but you are legally not required to do so. You may elect to submit some,
but not all, of your claims to Medicare electronically. Submitting just some claims
electronically does not impact your small provider status nor obligate you to submit all
of your claims electronically.
ed Change Request #: 2966 Medlearn Matters Number:
MM2966
Unusual Circumstance Waivers
Of the eleven circumstances when paper claim submission is still permissible, a
written waiver request is to be submitted to Medicare only for circumstance 9 for an
"unusual circumstance." You are expected to assess yourself to determine if any
of the other circumstances apply to your situation to permit you to submit some or all of
your claims on paper. CMS has delegated certain authority to the Medicare contractors
(carrier, DMERC, or intermediary) to determine whether an "unusual circumstance"
applies. So, if you believe you should qualify for a waiver as result of an "unusual
circumstance" you must submit a letter to the Medicare carrier, DMERC, or
intermediary to whom you submit your claims. The letter must explain the nature of the
"unusual circumstance" and indicate why you believe this circumstance prevents
you from submitting electronic claims to Medicare. Keep in mind that in some cases, an
"unusual circumstance" or the applicability of one of the other exception
criteria may be temporary. In this case, the related waiver would also be temporary. Once
the unusual circumstance no longer applies, you will again be required to submit your
claims to Medicare electronically. Also, some exception and waiver criteria apply to only
a specific type of claim, such as secondary claims when more than one other payer is
primary. You must submit electronically other types of claims that are not covered by an
exception or waiver
Important Dates to Know
EFFECTIVE DATE: October 16, 2003
IMPLEMENTATION DATE: January 20, 2004
Related Instructions
Please refer to the following sections of the Medicare Claims Processing Manual Chapter 24
- EDI Support Requirements for additional information:
90 - Mandatory Electronic Submission of Medicare Claims
90.1 - Small Providers and Full-Time Equivalent Employee Assessments
90.2 - Exceptions
90.3 - "Unusual Circumstance" Waivers
90.3.1-Unusual Circumstance Waivers Subject to Provider Self- Assessment
90.3.2 - Unusual Circumstance Waivers Subject to Medicare Contractor Approval
90.3.3 - Unusual Circumstance Waivers Subject to Contractor Evaluation and CMS Decision
90.4 - Electronic and Paper Claims Implications of Mandatory Electronic Submission
90.5 – Enforcement
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