(Medicare Claims Processing Manual)

A. All providers and clearinghouses that wish to obtain Medicare beneficiary data must apply to A/B MACs, DME MACs or other contractor if designated by CMS for access to the records.   B. Providers and clearinghouses must submit each query to the A/B MACs, DME MACs or other contractor if designated by CMS with which they are registered.  CMS supports multiple EDI and non -EDI methods for obtaining eligibility data, including ASC X12 270/271 eligibility (see IOM Pub. 100- 04 Chapter 31 for more information on the ASC X12 270/271 eligibility transaction).   C. When an inquiry is submitted, the A/B MAC, DME MAC, HETS 270/271, or other contractor if designated by CMS must be able to ensure that:    An EDI agreement has been signed by the provider;   A TPA has been signed by the clearinghouse; and   Each inquiry identifies the provider that initiated the query and to which the response will be routed.   D. Providers must be notified that:    they may obtain eligibility data only for the approved use of pre paring accurate Medicare claims;    access to eligibility data is limited to individuals within a providers organization who are involved in claim preparation and submission; and    they and their authorized third party agents must agree not to request eligibility data for a beneficiary unless the provider has been contacted by the beneficiary, a personal representative of a beneficiary such as a relative or friend, or a health care provider currently treating the beneficiary concerning provision of heal th care services or supplies to the beneficiary.   E. Medicare contractors, as designated by CMS, must:    Provide notification of these requirements to all providers requesting electronic receipt of eligibility data;    remind providers to notify them when the re is a change in clearinghouse, arrangements cease with a clearinghouse, or the provider leaves the Medicare program;   delete each provider from their EDI eligibility security file if there is no longer a business relationship between the Medicare contractor and provider, or if the Medicare contractor or the provider is no longer serving the Medicare program; and   remind providers, clearinghouses and other third parties that access rights to beneficiary eligibility data may be revoked if they fail to adhere to the requirements for access.   40.2.2.5 - EDI Enrollment and EDI Claim Record Retention  (Rev. 2965, Issued: 05- 23-14, Effective: 07-25-14, Implementation: 07-25-14)  In order for an entity to become an EDI trading partner, an EDI enrollment form must be completed, approved, and on file with an A/B MAC or CEDI.  A/B MAC or CEDI are required to retain all EDI enrollment forms according to the same CMS Records Schedule retention requirements that apply to the CMS- 855 Medicare Enrollment Application.   The paper claim retention schedule can be found at Pub 100-01, Chapter 7, Section 30: http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Downlo ads/ge101c07.pdf    Once a trading partner has been tested and approved for electronic submission of claims, they can begin submitting electronic claims to Medicare. A/B MAC, DME MACs or CEDI are required to retain electronically filed claims under the same CMS Records Retention Schedule retention requirements that apply to hardcopy claim.   40.2.3 - General EDI Outreach Activities  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  A/B MACs, DME MACs and CEDI are to actively encoura ge providers to increase their use of EDI transactions.  Also see  60 of this Chapter for EDI Edit Requirements.  Specific outreach requirements are included in the CMS requirements for implementation of new or revised EDI standards.  A/B MACs, DME MACs a nd CEDI are also required to notify providers about the need to file most claims with Medicare electronically. See  90 for specific referenced to Mandatory Submission of Medicare Claims. In general, A/B MACs, DME MACs and CEDI must:   1. Feature information on EDI during trade shows, vendor fairs, educational forums, and vendor association meetings that they sponsor or in which they participate;   2. Provide educational information on EDI to providers identified in internal analysis described in Se ction 40.2.3.1 as well as to the software vendors and clearinghouses that serve or market services to Medicare providers;   3. Make themselves available whenever possible, and invited to participate as an EDI speaker on the agenda of organized provider group meetings, such as state or local chapters of AAHAM, HFMA, MGMA, EDI user groups, state and local medical societies, and other provider and related vendor trade groups.  DME MACs shall participate in regional meetings that entail supplier use of EDI; and    Include specific and meaningful EDI messages in provider newsletters, addressing the themes described in Section 40.2.3.4 below, other issues that may be pertinent to the A/B MAC (B), DME MACs, or A/B MACs (A) geographic area, and as directed in individua l EDI instructions issued by CMS.  A/B MACs, DME MACs and CEDI are expected to point out the advantages to providers in the use of EDI transactions.  See the Medicare Beneficiary and Providers Communication Manual (100- 09) for definitive guidance on Medica res provider outreach requirements.  Provider outreach activities, including those that involve EDI are funded through the Provider Education and Training budget issued to Medicare contractors.   40.2.3.1 - A/B MAC and DME MAC Analysis of Internal Informat ion (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs and  DME MACs must contact providers with the highest number of paper claim transactions to have them begin submission of claims electronically as required under 90 of this chapter for ASCA enforcement Reviews. A/B MACs, DME MACs, and CEDI are also to strongly encourage providers to conduct their claims status, beneficiary eligibility, payment and remittance advice transactions electronically.    40.2.3.2 - Contact Wi th New Providers  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs must conduct an analysis of the capability of each provider (including physicians and suppliers) that contact a Medicare contractor to begin submission of Medicare claims, or for DME MACs, when notified by the National Supplier Clearinghouse that new supplier identification numbers have been issued.  A/B MACs  shall use provider education to ensure that all providers/submitters are aware that EDI transacti ons are to be presented as the normal mode of business for Medicare claims, claim status, and remittance.  A/B MACs  shall also use provider education to ensure that all providers/submitters are aware that EFT is the normal mode for funds transfer. See Chap ter 31 for HETS information on eligibility verification ASC X12 270/271 eligibility transaction queries.  Where the provider does not have the related capability, A/B MACs, DME MACs and CEDI are to inform the providers of available options to begin use of EDI, e.g., list of vendors and clearinghouses and billing services, availability of Medicares free software.   40.2.3.3 - Production and Distribution of Information to Increase Use of EDI (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs, DME MACs, and CEDI are required to post information on their provider web page to educate and influence providers in all aspects of EDI.  They must include the following information at a minimum:    Earlier payment of electronic claims that comply with HIPAA standards requirements;    The benefit of earlier detection of errors via edits conducted upon submission of electronic transactions;    The relative ease of use of EDI and the support available from the contractor to assist them in beginning use of EDI transactions;    Advantages of online correction of errors (A/B MAC (A) only);    Lower administrative, postage, and handling costs;    Electronic adjustments (A/B MAC (A)  only);    Availability of free software:   o PCACE Pro32 -  Part A/B and D ME;  o Medicare Remit Easy Print Software (MREP) -  Part B and DME; and   o Medicare Standard Electronic PC Print Software (PC Print) -  Part A/B.   o Availability of batch claims status inquiries. The information must be updated on a regular basis.  Availability of batch claims status inquiries. The information must be updated on a regular basis.  A/B MACs, DME MACs, and CEDI are encouraged to issue these materials via the Internet or E -Mail when possible, but paper copies may be distributed where most cost effect ive or when a provider may not have Internet or E- Mail access.   40.2.3.4 - Production and Distribution of Material to Market EDI  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  A/B MACs, DME MACs, and CEDI are required to produce and distribute material to educate and influence providers in all aspects of EDI.  They must include the following themes in published material:   1. Earlier payment of claims because of different payment floor requirements;  2. The benefit of earlier detectio n of errors via edits; 3. The relative ease of EDI and support available;  4. Advantages of online correction of errors (A/B MAC (A) only); 5. Lower administrative, postage, and handling costs; 6. Electronic adjustments (A/B MAC (A) only);  7. Availability of free software;  8. Claims status inquiry; and  9. Eligibility query.   They must include in written materials testimonials and/or case studies from providers and facilities that have benefited from using EDI transactions.   These materials may be pr oduced in-house or by local printing companies.  The contents must be maintained up to date.  Therefore, A/B MACs, DME MACs, and CEDI must carefully plan print quantities to match planned distribution to avoid unnecessary waste.  They must make the materia l available to staff that have contact with the provider community and make arrangements for distribution at trade shows and seminars that the A/B MACs, DME MACs, and CEDI do not attend as well as those that they do attend.  40.2.4 - Trading Partner Management  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  Medicare FFS Trading Partner Agreement is comprised of two forms: 1) EDI Registration and 2) EDI Enrollment.  The forms are identified under CMS form 10164 and can be accessed at:  EDI Registration - https://www.cms.gov/cmsforms/downloads/CMS10164A.pdf and  EDI Enrollment - https://www.cms.gov/cmsforms/downloads/CMS10164B.pdf   40.2.4.1 - User Guidelines  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs, and CEDI must make information available to potential users (preferably via their Web page or the Internet) of each EDI transaction supported by Medicare with detailed information on:    The telephone numbers of appropriate staff to contact to:   o Get started with electronic billing and other EDI transactions; and  o Obtain on- going support for electronic transactions.   o Testing requirements and the submitters and A/B MACs, and CEDI level of responsibility throughout each step of the testing process. See Section 40.1.2.1. for further testing details;   The availability of the appropriate specifications for providers and instructions for accessing these via the Internet or other cost effective means;    The availability  of the A/B MACs to provide  providers bulletins via the Internet and/or bulletin board system;    The availability of the A/B  MACs, and CEDI to provide EDI instructions or procedures via the Internet and/or bulletin board system;    The availability of the A/B MACs, and CEDI to provide free Medicare EMC software;    The availability of the A/B MACs free PC -Print software and the A/B  MACs, and CEDIs free Medicare Remit East Print (MREP) software for the printing of the Electronic Remittance Advice.    Login requirements;    Hours of operation, system and support;    Telecommunication options and requirements;    Procedures for updating submit ters with any billing changes;    EDI formats required for input to the A/B MACs and CEDI system.  These specifications must be in sufficient detail for the submitters use, and must include information regarding code, record length(s), field positioning within record(s), labeling and any other conventions necessary for compatibility with the A/B MACs or CEDI system;