(Medicare Claims Processing Manual)

When A/B MACs or DME MACs finish each providers ASCA review, the A/B MAC or DME MAC must enter the outcome to the provider file (see 90.5.2), except where identified as shared system responsibility, as well as enter the specific unusual circumstance when result code UC applies.   The group code CO (provider financial liability) is to be used with reason code 96 (non-covered charges), remark co de M117 (Not covered unless submitted by electronic claim), and remark code MA44 (No appeal rights).  Adjudicative decision based on law for the entire billed amount in the remittance advice sent to the provider for claims when denied as submitted on paper .  If a provider is a candidate for an ASCA enforcement review and the provider is also undergoing a fraud or abuse investigation, the A/B MAC or DME MAC has discretion to exclude that provider from the ASCA enforcement review that quarter if it could inte rfere with the fraud/abuse investigation, or alternately, may combine the ASCA review with the fraud/abuse investigation.  If an ASCA enforcement review is not conducted due to possible interference, and the provider is subsequently cleared of fraud or abuse, the ASCA enforcement review is to be conducted when that fraud/abuse investigation is completed.   Most types of ASCA exceptions/waivers apply to individual claim types only, or to submission of paper claims for temporary periods.  If a provider is sele cted for ASCA review, and the contractor determines that most of the paper claims submitted for that provider for that period:   1. Were for MSP claims when there is more than one primary payer, or for mass inoculations, or similar types of claims allowed to be submitted on paper; or   2. Were submitted on a temporary basis as result of power and communication disruption resulting from a natural disaster or similar problem outside the control of the provider; AND   3. The number of paper claims submitted for the provi der during that quarter that did not meet such criteria would not have been high enough to have resulted in selection of that provider for ASCA review in the absence of the excepted/waived claims, the contractor is to terminate that review.  THEN,   The A/B  MAC or DME MAC must enter provider ASCA review result WA (see 90.5.2) to trigger Exhibit letter F, and an A/B MAC (A) must issue letter F.   NOTE:   WA or issuance of letter F to a provider that is being waived for a reason other than the number of FTEs em ployed does not preclude the provider from A/B MAC, or DME MAC selection for review during subsequent quarters.   A/B MACs and DME MACs are not to maintain a provider FTE database, or establish a separate database of waived providers, unless an unusual sit uation waiver decision is made as result of a providers request for approval of a waiver (see 90.3.2), or as result of an ASCA review and either A/B MACs or DME MACs provider ASCA determination WA or UC (see 90.5.1) applies, or an A/B MACs (A) has issue d letter F for other than the small provider exception.  Each A/B MAC or DME MAC will maintain a local Excel spreadsheet of unusual situation waivers and requests with column headings for the name, address, legacy and NPI provider number, whether a reque sted unusual circumstance waiver was approved or denied, the effective and termination dates for an approval (if applicable), and the unusual circumstance identified in the request.   A/B MACs and DME MACs must be able to submit this spreadsheet to CMS when requested or could be asked to submit data from the spreadsheet in a report to CMS.  Provider entries in this spreadsheet shall be retained for the same period that A/B MACs and DME MACs are required to retain claims.   C. Post -Review Actions   If followi ng the start of paper claim denials, a provider subsequently submits documentation to establish that they actually had met criteria for submission of paper claims by that 91st day, the A/B MAC or DME MAC must enter SM, WA or UC as appropriate in the shared  system ASCA review result field.  This will trigger the shared system to have Exhibit letter F issued and will eliminate further paper claim denials for the provider.  An A/B MAC (A) must notify FISS to terminate denial of that providers paper claims.  T he shared system is not to reprocess any paper claims previously denied as on paper for that provider unless the provider resubmits those claims.   If a provider submits documentation to establish eligibility to submit paper claims but that eligibility is effective after the 91st day, the A/B MAC or DME MAC shall enter the date when the provider actually became eligible to submit paper claims in the appropriate field in the shared system ASCA review result screen (see 90.5.2).  There is no corresponding A/ B MAC (A) process for this, but it is considered unlikely that this situation would occur with an institutional provider.  If a provider resubmits denied claims, services furnished on or after the date of eligibility to submit paper claims may be paid but services furnished after the 90th day through the day before the provider became eligible to submit paper claims may not be paid.  They must be denied as furnished during a period for which the provider was required to bill Medicare electronically.   90.5.4 - Submission of Claims that May Always be Submitted on Paper by Providers Not Otherwise Eligible to Submit Paper Claims (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  If a provider determined to be ineligible to submit most types of claims on paper contacts any MAC to complain because a claim that contained services permitted to be submitted on paper (see 90.2) was denied, the MAC is to manually process and pay that claim.  These claims will only be paid at the providers re quest, assuming all other requirements are met for coverage and payment of that claim or certain services included in that claim.  Medicare systems are incapable of identifying and paying certain types of paper claims, or only certain services included in paper claims, when a provider has been determined to be otherwise ineligible for payment of all other paper claims.   90.6 - Provider Education  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Medicare contractors were required to include information on their provider Web site and in a newsletter by April 2004 to notify providers of/that:   1. Providers that do not qualify for a waiver as small and that do not meet any of the remaining exception or waiver criteria must submit their claims to Medicare electronically;   2. Small provider criteria and that small providers are encouraged to submit as many of their claims electronically as possible;   3. FTE definition and calculation methodology;   4. Exception criteria;   5. Unusual circumstance criteria;   6. Self -assessment requirements;   7. Process for submission of an unusual circumstance waiver;   8. Additional claims, such as certain claim types not supported by free billing software, that must continue to be submitted on paper pe nding any contractor or shared system modifications to enable those claims to be submitted electronically;   9. Submission of paper claims constitutes an attestation by a provider that at least one of the paper claim exception or waiver criterion applies at  the time of submission;   10. Repercussions of submitting paper claims when ineligible for submission of paper claims;  11. Post -payment monitoring to detect providers that submit unusually high numbers of paper claims for further investigation; and   12. W aiver request submitted by providers should include the providers name, address, contact person, the reason for the waiver, why the provider considers enforcement of the electronic billing requirement to be against equity and good conscience, and any othe r information the contractor deems appropriate for evaluation of the waiver request.   90.7 - Application of Electronic Data Interchange Enrollment Information and ASCA Enforcement Review Decisions from Other Medicare Contractors to the Same Providers When They Bill the Railroad Retirement Board Specialty MAC (RRB SMAC)  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  ASCA did not differentiate among Medicare contractors or between Railroad (RR) and non-RR Medicare for applicatio n of the electronic billing requirement.  Section 90.3.1 of this chapter indicates that a provider that submits fewer than 10 claims to Medicare per month on average (fewer than 120 claims per year) is permitted to continue to submit paper claims.  As resu lt of the distribution of RR retirees though, it is not unusual for a single provider to only treat a small number of RR Medicare patients and to submit fewer than 10 claims to the RRB SMAC per month.  The same providers that treat RR Medicare patients als o treat non- RR Medicare beneficiaries however, and in most cases do submit more than 10 claims per month in total to one or more non- RR Medicare contractors.  As result, when selecting providers for an ASCA Enforcement Review, the RRB SMAC shall not exclude a provider from consideration for review simply because the quarterly ASCA report indicates the provider submitted fewer than 10 claims to the RRB SMAC.  In a departure from the rule as it applies to non- RRB SMAC Medicare contractors, submission of fewer than 10 claims per month to the RRB SMAC does not automatically qualify a provider for waiver of the electronic claims submission requirement.   Providers that submit paper claims to multiple Medicare MACs, including both RR and non-RR MACs, could have an ASCA Enforcement Review conducted by each of those contractors.  If a non- RR Medicare MAC determines that a provider does not meet any criteria which would permit that provider to continue to submit Medicare claims on paper and notifies a provider (letter E is triggered) that all paper claims submitted on or after a specific date will be denied, that same decision is to be applied to that provider if submitting paper claims to the RRB SMAC regardless of whether that provider would submit 10 or more paper cl aims to the RRB SMAC monthly.   Provider enrollment information from non- RR MACs is sent to the RRB SMAC weekly by the MCS maintainer in a Provider Enrollment System file called SuperPES .  As a condition for submission of claims to the RRB SMAC, a provider must first enroll for submission of claims to non- RR Medicare.  The RRB SMAC uses SuperPES to determine whether any provider that sends them a claim, but that does not have a record in the RR provider enrollment system (PES), is already enrolled in non- RR Medicare.  If so, the RRB SMAC then uses the SuperPES information to establish a record for that provider in the RR PES file, or if not, rejects those claims as there is no indication t hat provider has enrolled in Medicare.  SuperPES is manually searched by RRB SMAC representatives.  It would be difficult and possibly impossible to automatically update PES due to the differences in RR and non-RR legacy provider numbers.  Addition of NPIs may not appreciably improve the ability to make one to one matches since providers can obtain more than one NPI or fewer NPIs than legacy identifiers.  Although supplemental information is submitted on claims that can often be used to match between an NPI and a single legacy identifier, there is not as  much supplemental information in the SuperPES and PES files that could be used to help make a match between the files in the absence of a claim.   SuperPES includes fields (see the date and ASCA decision fields in 90.5.2) for the reporting of an ASCA review result, the date of that ASCA decision and the NPI associated with the providers non- Railroad PIN.  Multi is entered in that field if more than one NPI is associated with a PIN.  The RRB SMAC shall check SuperPES for the availability of ASCA Enforcem ent Review information when selecting providers on PES for ASCA Enforcement Reviews, as well as when first establishing a PES record for a provider.  If an ASCA review decision (NE, SM, WA or UC) is in SuperPES, that decision and the effective date of that  decision in SuperPES must be entered into that providers record in PES.  In lieu of NE however, the RRB SMAC shall enter NR in PES to indicate that the not eligible determination was made by a contractor other than the RRB SMAC.  If either SM, WA or UC applies, the effective date of the decision is the later of the date in SuperPES when that contractor began the most recent ASCA review or the date the provider became eligible to submit paper claims when that is later than the date that the denial of claims began as result of a prior NE/NR decision.  A future date may not be entered in PES for a NE/NR decision.  A future NE effective date in SuperPES signifies that the contractor has not yet completed the ASCA review and that the decision is sti ll tentative. See 90.7.1 for further use of the ASCA decision codes to determine when to issue ASCA review letters.