(Medicare Claims Processing Manual)

As new HIPAA versions are named, contractors are required to report their implementation progress to CMS via transition reporting. Data collection will be achieved via an external, secure web -based reporting tool designed to support long  term, short term, and ad- hoc data gathering efforts, such as Electronic Data Interchange statistics and performance metrics.   The contractor shall obtain access to the web -based reporting tool via self enrollment  contingent on CMS approval. Current reports vary in frequency from weekly to monthly; however, any future efforts will reflect the most appropriate time period. Contractors will always be notified via Technical Direction Letter (TDL) on the required start ing date of any transition reporting, the content of the transition data, and the frequency of the reporting effort.   Contractors will utilize the reporting functionality in their front end systems, in CEM, in the Shared System Maintainer, and/or in CEDI t o provide CMS with their EDI HIPAA transition reports.  80.5 - Administrative Simplification and Compliance Act (ASCA) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Contractors are required to report the status of their ASCA enforcement activities on a monthly basis. ASCA enforcement data will be submitted via an external, secure web -based reporting tool.   The contractor shall obtain access to the web -based reporting tool via self enrollment contingent on CMS approval. Contractors will always be notified via Technical Direction Letter (TDL) of any changes in the reporting requirements of the ASCA enforcement reporting, the content of the ASCA enforcement data, and the frequency of the ASCA enforcement reporting effor t.  Contractors shall reference Pub 100 -04, Chapter 24, Section 90 for the complete details and requirements on ASCA enforcement.   90 - Mandatory Electronic Submission of Medicare Claims  (Rev. 3491, Issued: 04- 05-16, Effective: 07- 01-16, Implementation: 07- 05-16)  Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L. 107 -105, and the implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement under Medicare, except from small providers, be submitted elec tronically as of October 16, 2003, with limited exceptions.  Initial claims are those claims submitted to a A/B MAC or DME MAC for the first time, including resubmitted previously rejected claims, claims with paper attachments, demand bills, claims where M edicare is the secondary payer, and non -payment claims.  Initial claims do not include adjustments or claim corrections submitted A/B MAC or DME MAC on previously submitted claims or appeal requests.   Medicare is prohibited from payment of  claims submitted  in a non- electronic manner that do not meet the limited exception criteria.  Claims required to be submitted electronically effective October 16, 2003, and later must comply with the appropriate claim standards adopted for national use under HIPAA (see se ction 70 of this chapter).  The mandatory electronic claim submission requirement does not apply to claims submitted by beneficiaries or by providers that only furnish services outside of the United States, claims submitted to Medicare managed care plans, to health plans other than Medicare, or for purchased only Expatriate beneficiary Durable Medical Equipment Prosthetics Orthotics Supplies (DMEPOS) claims.   90.1 - Small Providers and Full -Time Equivalent Employee Self -Assessments  (Rev.: 4388; Issued: 09- 06-19; Effective: 10- 07-19; Implementation: 10 -07-19)  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 full -time equivalent (FTE) employees; 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 considers all providers that have fewer than 25 FTEs and that are required to bill a Medicare A/B MAC (A)to be small; and considers all physicians, practitioners, facilities, or suppliers with fewer than 10 FTEs and that are required to bill a A/B MAC (B) or DME MAC to be small.   The ASCA law and regulation do not modify pre -existing laws or employer policies defining full time employment.  Each employer has an established policy, subject to certain non -Medicare State and Federal regulations, that define the number of hours employees must work on average on a  weekly, biweekly, monthly, or other basis to qualify for full -time benefits.  Some employers do not grant full- time benefits until an employee works an average of 40 hours a week, whereas another employer might consider an employee who works an average of  32 hours a week to be eligible for full -time benefits.  An employee who works an average of 40 hours a week would always be considered full time, but employees who work a lesser number of hours weekly on average could also be considered full time accordin g to the policy of a specific employer.   Everyone on staff for whom a health care provider withholds taxes and files reports with the Internal (Revenue Service (IRS) using an Employer Identification Number (EIN) is considered an employee, including if appl icable, a physician(s) who owns a practice and provides hands on services and those support staff who do not furnish health care services but do retain records of, perform billing for, order supplies related to, provide personnel services for, and otherwis e perform support services to enable the provider to function.  Unpaid volunteers are not employees.  Individuals who perform services for a provider under contract, such as individuals employed by a billing agency or medical placement service, for whom a provider does not withhold taxes, are not considered members of a providers staff for FTE calculation purposes when determining whether a provider can be considered as small for electronic billing waiver purposes.   Medical staff sometimes work part time , or may work full time but their time is split among multiple providers.  Part time employee hours must also be counted when determining the number of FTEs employed by a provider.  For example, if a provider has a policy that anyone who works at least 35 hours per week on average qualifies for full -time benefits, and has 5 full -time employees and 7 part -time employees, each of whom works 25 hours a week, that provider would have 10 FTEs (5+[7 x 25= 175 divided by 35= 5]).  In some cases, the EIN of a paren t company may be used to file employee tax reports for multiple providers under multiple provider numbers.  In that instance, it is acceptable to consider only those staff, or staff hours worked for a particular provider (National Provider Identifier (NPI) ) to calculate the number of FTEs employed by that provider.  For example, ABC Health Care Company owns hospital, home health agency (HHA), ambulatory surgical center (ASC), and durable medical equipment (DME) subsidiaries.  Some of those providers may bil l A/B MACs or DME MACs.  All have separate provider numbers but the tax records for all employees are reported under the same EIN to the IRS.  There is a company policy that staff must work an average of 40 hours a week to qualify for full time benefits.   Some of the same staff split hours between the hospital and the ASC, or between the DME and HHA subsidiaries.  To determine total FTEs by provider number, it is acceptable to base the calculation on the number of hours each staff member contributes to the support of each separate provider by provider number.  First, each provider would need to determine the number of staff who work on a full -time basis under a single provider number only; do not count more than 40 hours a week for these employees.  Then each provider would need to determine the number of part -time hours a week worked on average by all staff who furnished services for  the provider on a less than full - time basis.  Divide that total by 40 hours to determine their full- time equivalent total.  I f certain staff members regularly work an average of 60 hours per week, but their time is divided 50 hours to the hospital and 10 hours to the ASC, for FTE calculation purposes, it is acceptable to consider the person as 1 FTE for the hospital and .25 FTE for the ASC.  In some cases, a single provider number and EIN may be assigned, but the entitys primary mission is not as a health care provider.  For instance, a grocery stores primary role is the retail sale of groceries and ancillary items including ov er the counter medications, but the grocery store has a small pharmacy section that provides prescription drugs and some DME to Medicare beneficiaries.  A large drug store has a pharmacy department that supplies prescriptions and DME to Medicare beneficiar ies but most of the stores revenue and most of their employees are not involved with prescription drugs or DME and concentrate on non -related departments of the store, such as film development, cosmetics, electronics, cleaning supplies, etc.  A county government uses the same EIN for all county employees but their health care provider services are limited to furnishing of emergency medical care and ambulance transport to residents.  For FTE calculation purposes, it is acceptable to include only those staff  members of the grocery store, drug store, or county involved with or that support the provision of health care in the FTE count when assessing whether a small provider waiver may apply.   Support staff who should be included in the FTE calculation in these  instances include but are not necessarily limited to those that restock the pharmacy or ambulance, order supplies, maintain patient records, or provide billing and personnel services for the pharmacy or emergency medical services department if under the s ame EIN, according to the number of hours on average that each staff member contributes to the department that furnishes the services or supplies for which the Medicare provider number was issued.   Providers that qualify as small automatically qualify fo r waiver of the requirement that their claims be submitted to Medicare electronically.  Those providers are encouraged to submit their claims to Medicare electronically, but are not required to do so under the law.  Small providers may elect to submit some  of their claims to Medicare electronically, but not others.  Submission of some claims electronically does not negate their small provider status nor obligate them to submit all of their claims electronically.   In the event that a provider uses a clearing house or a billing agent to submit claims, it is the number of FTEs on the providers staff, not those on the staff of the billing agent or the clearinghouse, that determine whether the provider may be considered small for Medicare paper claim submission p urposes.   90.2 - Exceptions (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  It has been determined that due to limitations in the claims  transaction formats adopted for national use under HIPAA, it would not be possible in some cases to submit certain claims to Medicare electronically.  Providers are to self -assess to determine if they meet these exceptions.  At the present time, only the following claim types are considered to meet this condition for self -assessment purposes:   1. Roster billing of inoculations covered by Medicare-Although flu shots and similar covered vaccines and their administration can be billed to Medicare electronically, one claim for one beneficiary at a time, some suppliers have been permitted to submit a single claim on paper with the basic provider and service data and to attach a list of the Medicare beneficiaries to whom the vaccine was administered and related identification information for those beneficiaries. This is referred to as roster billing.  The claim IGs adopted under HIPAA provide for submission of single claims to a payer for single individuals, but cannot be used to submit a roster bill for multiple individuals.