(Medicare Claims Processing Manual)

In the case of a provider that has more than one PIN or NSC number used to bill that quarter which are covered by the same TIN, apply the reporting directions located at the end of Part 1.   Part 3 -This Part must contain information on those providers that submitted only paper claims and who submitted fewer than 100 paper claims during that quarter.  Part 3 must indicate the name; TIN; legacy provider identifier (PIN or NSC number); the number of claims submitted for each listed provider that quarter; date the providers most recent ASCA enforcement review began; effective date of the providers most recent A SCA enforcement review decision; if for the RMC, the ZIP Code (extended if available); and ASCA review result code from that most recent review.  This part must be organized in descending order according to the number of paper claims submitted for each provider during that quarter.   In the case of a provider that has more than one PIN or NSC number used to bill that quarter which are covered by the same TIN, apply the reporting directions located at the end of Part 1.   Part 4 -The total number of providers f or which one or more paper claims were submitted during the quarter.  The number in Part 4 is intended to represent the unduplicated total of all providers that could potentially be considered for ASCA Enforcement Review selection.   NOTE :  Shared systems h ave the option to use adjudicated or processed claims, rather than submitted claims, for preparation of the report if that would take less time or resources to prepare.  If using adjudicated or processed claims instead of submitted claims, this must be noted in the report.  B. Identification of Providers to Be Reviewed, Letters to be Issued and Determinations Made A check block or field that can be used to identify those providers being selected for review must appear at the beginning of the data line for each listed provider.  The report produced for the RRB SMAC must permit the RRB SMAC to designate whether letter C or H is to be issued.  The block or field will be completed by the contractors to identify those providers chosen for ASCA review. When an A/B MAC (B) and DME MAC completes that block/field, the shared system will notify the A/B MAC (B) and DME MACs correspondence system by the next business day to release Exhibit letter C (or H in the case of the RRB SMAC) to that provider and will furnish the start and end date of the quarter on which the review is based (for contractor entry in the paragraph that follows e in Exhibit letter C.)  The shared system will automatically begin counting days since letter C, G (manually triggered by the RRB SMAC) or H was triggered and will trigger release of letter D 45 -days after letter C, G or H (or the first business day after the 45th day when the 45th day is on a weekend or holiday), and will count elapsed days to begin denying paper claims from that provider effective with the 91st day after letter C, G or H was triggered.   The shared system must permit an A/B MAC (B), and DME MAC to cancel the block/field for issuance of letter C or H in the event completed in error, as long as the correction is made on the same business day as the erroneous entry.  90.5.3 - Contractor Roles in ASCA Reviews  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  A. Identification of Those Providers to be Reviewed   Separate funding will no longer be issued for these reviews annually.  Each A/B MACs (B) and DME MAC shall conduct an ASCA review annually of 20% of those providers still submitting paper bills.   The following providers will be included in the quarterly report, but contractors are not to select a  provider for review that quarter if:    A prior quarter review is underway and has not yet been completed for that provider (start date of prior review is listed in the report but not yet an enforcement decision effective date);    The provider has been reviewed within the past two years, determined to be a small provider, and there is no reason to expect the providers small status will change for at least two years (provider file past ASCA review result was SM and completion date of that review is  less than 24 months in the past); or   Fewer than 30 paper claims were submitted by the provider for the quarter.  When calculating 20% of providers still submitting paper claims, exclude those providers mentioned above who will not be considered for an AS CA review.  For example, the A/B MAC (B) or DME MAC receives claims for 3,200 providers but only 2,000 of those submit any paper claims, and 1,800 submit more than 30 paper claims per quarter.  600 of that 1,800 have been reviewed within 2 years of the quarter in which a Medicare contractor is now determining which providers should be reviewed during that quarter and determined to be small.  75 of the paper billers in the quarterly report had reviews begin the prior quarter which are still open.  That leave s a balance of 1,125 providers who could be subject to an ASCA review during the current quarter.  1,125 is the total of the universe of providers that are candidates for review during the current quarter and the number of the universe to be reported to CMS in the A/B MACs (B) or DME MACs monthly ASCA report.  20% of 1,125 is 225 and  of 225 is 56 .  That contractor is expected to begin at least 56 new ASCA reviews during the current quarter.  By the end of the fiscal year (FY), that A/B MAC (B) or DME MA C is expected to have begun ASCA reviews of the average of the provider universe totals for the quarters multiplied by 20%.  In this example, if 1,125 providers was the average number of providers considered for ASCA review for the 4 quarters of the FY and  the contractor began ASCA reviews of 225 of those providers by the end of the FY, that A/B MAC (B) or DME MAC will have met the 20% target for that FY.   1. A/B MAC (B) and DME MAC  - Specific Selection Requirements -A/B MACs (B) and DME MACs will determine the best candidates for review from the quarterly report and will complete the block/field to identify the selected providers in the quarterly report and trigger release of Exhibit letter C to those providers.  (The A/B MACs (B) and DME MACs must furnish t he appropriate URLs for the last paragraph of the letter.)  Select candidates as follows:   a. Two -thirds from Part 1 providers beginning with those that have the largest number of paper claims and issuing letters in descending order; and   b. One third from Part 2 providers also beginning with those that have the largest number of paper claims and issuing letters in descending order.  NOTE:  In the case of a provider that submits claims under more than one PIN or NSC number, all of which are under the same TIN, and for which there are multiple entry lines in the quarterly report, the A/B MAC (B) and DME MAC shall combine the number of paper claims submitted under each of those PINs/NSCs when determining which providers to be selected for review.  For ASCA evaluation purposes, consider all of those paper claims as submitted by the same provider even though under different PINs or NSCs.  Complete the block/field for each of the providers lines in that case, but apply the same review result for each of the affected PINs/NSCs recorded for that provider.  In terms of number of reviews conducted, a review that involves multiple PINs or NSCs for the same provider is to be treated individually and multiple copies of letter C are to be issued.  If an A/B MAC (B) and DME MAC exhausts the Part 1 list and still has additional reviews to conduct in the quarter, the contractor is to increase the number of initial review letters sent to Part 2 providers.  If the Part 2 list is also exhausted for the quarter, and the contrac tor still has additional reviews to initiate, the contractor will begin to send initial review letters to those providers in Part 3 of the shared system quarterly report, again having letters issued in descending order beginning with those providers with t he largest numbers of paper claims.   A/B MACs (B) and DME MACs are to complete selection of providers to be reviewed by the end of the second month of each quarter.  B. Conducting the Reviews   If a provider responds to letter C or D (whether triggered by a n A/B MAC or DME MAC selection of the provider for review in the quarterly report or direct issuance of the letters by an A/B MAC (A)), but does not establish eligibility to submit paper claims, the A/B MAC (A) shall notify the shared system to begin denying paper claims submitted by that provider beginning on the 91st day after release of letter C and shall issue letter E.  The A/B MAC or DME MAC shall enter ASCA review result code NE  in the shared system ASCA review result field (see 90.5.2).  This will trigger the shared system to have Exhibit letter E released by the contractors correspondence system.   If a providers response to letter C or D establishes that the provider is eligible to submit paper claims to Medicare, the A/B MAC (A) shall issue provider letter F, and the A/B MAC or DME MAC shall enter ASCA review result code SM, WA or UC (see 90.5.2 as appropriate in the ASCA review result field).  This will trigger MCS or VMS to have letter F released.   A/B MACs or DME MACs have authority to delay imposition of denial of paper claims for up to 30-days if the provider responds to letter C or D and indicates all changes needed to submit their claims electronically cannot be completed by the 90th day after letter C, but will be completed within 30 addi tional days.  An A/B MAC or DME MAC should approve an extension request of up to 30 days, if the  A/B MAC or DME MAC  has no reason to suspect the provider may not complete the changes by the specified date.   When an extension is approved, an A/B MAC (A) mus t reset the effective date of paper claim denials as needed so FISS does not begin to deny paper claims from that provider prior to expiration of the extension period.  An A/B MAC or DME MAC must enter the new effective date (CCYYMMDD) when MCS or VMS is t o begin denying paper claims in the paper claim denial date field (see 90.5.2) and also enter NE in the ASCA review result screen/field.  MCS or VMS will begin to deny the providers paper claims on the date entered.   If based on prior experience with the  provider or knowledge of the extent of the changes the provider must make, the A/B MAC or DME MAC has reason to doubt the ability of the provider to complete the necessary changes by the 120th day, the MAC is to deny a providers extension request.  The A /B MAC (A) shall immediately notify FISS to begin denying paper claims from that provider beginning on the 91st day after issuance of letter C.  The A/B MAC or DME MAC shall enter NE in the ASCA review result screen/field; MCS or VMS shall begin to deny that providers paper claims on the 91st day after letter C was triggered.   The A/B MAC or DME MAC  does not have authority to approve more than one 30- day extension during the same review.  A/B MACs or DME MACs  must contact CMS/OIS/BAMG/Division of Transactions, Applications & Standards (DTAS) if a contractor representative thinks a providers request for an extension beyond the 120th day should be approved.  If a c  A/B MAC or DME MAC  does not endorse an extension request beyond the 120th day, the contractor should deny the request.  The A/B MAC or DME MAC shall enter NE in the ASCA review result screen/field.  If DTAS approval is requested by a contractor and DTAS does approve an extension, A/B MACs or DME MACs are to follow the requireme nts in the prior paragraph concerning resetting of the effective date for denial of that providers paper claims.   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 .