(Medicare Claims Processing Manual)

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.   Flu and pneumonia inoculations are often administered in senior citizen centers, grocery stores, malls, and other locations in the field.  It is not always reasonable or hygienic to use a laptop computer to register all necessary data to enable a HIPAA -compliant claim to be submitted electronically in such field situations, particularly when a single individual is responsible for collection of the data and administration of the inoculations.  Due to the low cost of these vaccinations, it is not always cost effective to obtain all of the data normally needed for preparation of a HIPAA -compliant claim.  Such suppliers rarely have a long -term health care relationship with their patients and do not have a need for the extensive medical and personal history routinely collected in most other health care situations.  It is in the interest of Medicare and public health to make it as simple as possible for mass inoculation activities to continue.  Although suppliers are encouraged to submit these claims to Medicare electronically, one claim for one beneficiary at a time, this is not required except in the case of multi- state companies that signed an agreement with a single Medicare contractor for submission of all flu shots to that single contractor for those states, and who agreed to submit those claims electronically as a condition for centralized billing of those inoculations.  In the absence of an electronic format that would allow a single claim for the same service to be submitted on behalf of multiple patients using abbreviated data, suppliers currently allowed to submit paper roster bills may continue to submit paper roster bills for inoculations.  This inoculation waiver applies only to injections such as flu shots frequently furnished in non-traditional medical situations, and does not apply to injections including flu shots when furnished in a traditional medical setting such as a doctors office or an outpatient clinic as a component of other medical care or an examination.  In traditional medical situations where the provider is required to bill the other services furnished to the patient electronically, a flu shot or other inoculation is also to be included in the electronic claim sent to Medicare for the patient.   2. Claims for paym ent under a Medicare demonstration project that specifies paper submission-By their nature, demonstration projects test something not previously done, such as coverage of a new service.  As a result of the novelty, the code set that applies to the new service may not have been included as an accepted code set in the claim implementation guide(s) adopted as HIPAA standards.  The HIPAA regulation itself makes provisions for demonstrations to occur that could involve use of alternate standards.  In the event a Medicare demonstration project begins that requires some type of data not supported by the existing claim formats adopted under HIPAA, Medicare could mandate that the claims for that demonstration be submitted on paper.  In the event demonstration data can be supported by an adopted HIPAA format, Medicare will not require use of paper claims for a demonstration project. Demonstrations typically involve a limited number of providers and limited geographic areas.   Providers that submit both demonstration and regular claims to Medicare may be directed to submit demonstration claims on paper.  Non- demonstration claims must continue to be submitted electronically, unless another exception or waiver condition applies to the provider.  3. Obligated to Accept as Payment in Full (OTAF) Medicare Secondary Payer (MSP) Claims when There is More than One Primary Payer - An OTAF adjustment (also see the Medicare Secondary Payment Manual) is made when a provider, physician or supplier agrees as result of negotiation or otherwise to receive a payment rate that is higher or lower than a payers normal allowed amount as payment in full for particular services or supplies.  By regulation, if a primary payers OTAF amount is lower than the charge for the related service that appears on the claim, Medicare must include the OTAF adjustment when calculating the amount of Medicares secondary payment.  The OTAF is identified in the CAS Segment with the Group Code of CO. The CO is used both on the ASC X12 835 remittance and the ASC X12 837 claim.  4. MSP Claims When There is More than One Primary Payer and More Than One Allowed Amount-In an MSP situation, Medicare needs to use a primary payers allowed and paid amounts to calculate the supplemental amount that can be paid by Medicare.  In some cases, a beneficiary is covered by more than one other primary payer.  Each of those other payers must complete adjudication before Medicare can process those claims.  The ASC X12 837 current HIPAA version IGs permit reporting of payment information from more than one other payer, but not for reporting of separate allowed amounts at the line or claim level for more than one payer.  As result of this limitation, when there is more than one primary payer, and the allowed amounts differ, a provide r is permitted to submit the claim to Medicare on paper, with the RA/EOB from each of the primary payers attached.   Except for OTAF claims when there is also more than one primary payer, or if a provider is small or meets one of the temporary exception cri teria, such as disruption of electricity or communications, no other types of MSP claims, such as MSP claims when there is only one primary payer, may be submitted to Medicare on paper. Claims submitted by Medicare beneficiaries.   90.3 - Unusual Circumstance Waivers  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Congress granted the Secretary considerable discretion to decide what other circumstances should qualify as unusual circumstances for which a partial (applies to certain claim types or for a defined period of time) or full waiver of the electronic claim submission requirement would be appropriate.  The Secretary delegated that authority to CMS.  In the event it is determined that enforcement of the electronic claim submission requirement would be against equity and good conscience as result of an unusual circumstance, CMS will waive the electronic claim submission requirement for temporary or extended periods.  In those situations, providers ar e encouraged to file claims electronically where possible, but electronic filing is not required.   CMS has in turn delegated certain authority to the A/B MACs or DME MACs to determine whether an unusual circumstance applies.  Providers who feel they should qualify for a waiver as result of an unusual circumstance must submit their waiver requests to the A/B MACs or DME MACs to whom they submit their claims.  The A/B MACs or DME MACs must issue a form letter (Exhibit A) in the event of receipt of a written waiver request that does not allege an unusual circumstance.   As required by the Privacy Act of 1974, letters issued to a provider to announce a waiver decision must be addressed to the organizational name of a provider and not to an individual (eithe r a sole practitioner, employee or the owner of the provider organization).  The organizational name is generally a corporate name under which the provider is registered as a Medicare provider or the name used to obtain an EIN from the IRS.  In some cases,  an unusual circumstance or the applicability of one of the other exception criteria may be temporary; in which case, the related waiver would also be temporary.  Once the criteria no longer apply, that provider is again subject to the Medicare electroni c claim submission requirement. Likewise, some exception and waiver criteria apply to only a specific type of claim, such as an OTAF secondary claim when there is more than one primary payer for only the current HIPAA version.  Other claim types not covere d by an exception or waiver must still be submitted to Medicare electronically, unless the provider is small or meets other exception or unusual circumstance criteria.   90.3.1 - Unusual Circumstance Waivers Subject to Provider Self -Assessment  (Rev. 2803, I ssued: 10 -28-13, Effective: 09-17-13, Implementation: 09-17-13)  The following circumstances always meet the criteria for waiver.  Providers that experience one of the following unusual circumstances are automatically waived from the electronic claim sub mission requirement for either the indicated claim type or the period when an unusual situation exists. A provider is to self- assess when one of these circumstances applies, rather than apply for contractor or CMS waiver approval. A provider may submit claims to Medicare on paper or via other non- electronic means when one of these circumstances applies.  A provider is not expected to pre- notify their A/B MACs or DME MACs that one of the circumstances applies as a condition of submission of non- electronic claims.    Dental claims -Medicare does not provide dental benefits.  Medicare does cover certain injuries of the mouth that may be treated by dentists, but those injury treatments are covered as medical benefits.  Less than .01 percent of Medicare expenditures were for oral and maxillofacial surgery costs in 2002. The ASC X12 837 professional claim TR3 standard for submission of medical claims requires submission of certain data not traditionally reported in a dental claim but which is needed by payers to adjudicate medical claims.  As result, Medicare contractors have not implemented the dental claim standard adopted for national use under HIPAA.  Due to the small number of claims they would ever send to Medicare, most dentists have not found it cost effective to invest in software they could use to submit medical claims to Medicare electronically.  For these reasons, dentists will not be required to submit claims to Medicare electronically.    Disruption in Electricity or Phone/Communication Services --In the event of a major storm or other disaster outside of a providers control, a provider could lose the ability to use personal computers, or transmit data electronically.  If such a disruption is expected to last more than 2 business days, all of the affected providers are automatically waived from the electronic submission requirement for the duration of the disruption.  If duration is expected to be 2 business days or less, providers should simply hold claims for submission when power and/or communication are restored.    A provider is not small based on FTEs, but submits fewer than 10 claims to Medicare per month on average (not more than 120 claims per year).  This would generally apply to a provider that rarely deals with Medicare beneficiaries.   4. Non-Medicare Managed Care Organizations  that are able to bill Medicare for copayments may continue to submit those claims on paper.  These claims are not process able by the MSPPay module and must be manually adjudicated by Medicare contractors.      90.3.2 - Unusual Circumstance Waivers Subject to a Contractor Evaluation for CMS Decision  (Rev.4096, Issued: 08- 03-18, Effective: 11-05-18, Implementation: 11-05-18)  A provider may submit a waiver request to their A/B or Durable Medical Equipment  Medicare Admin istrative Contractors (A/B or DME MACs) claiming other types of unusual circumstances  outside of  their control  prevent submission of  electronic claims. It is the responsibility of the provider to submit appropriate documentation including request application with Provider name, address, email, and phone number to establish the validity of  a waiver request in this situation . Requests received without documentation and as above stated information to fully explain and justify why enforcement of the requirement would be against equity  and good conscience  in these cases will be  denied. If the A/B MAC or, DME MAC agrees that the waiver request has merit, the request must be forwarded Centers for Medicare and Medicaid Services, Office of Information Technology, Applications Management Group, to the Division of Transactions, Applications & Standards (CMS/OIT/AMG/DTAS) Email box (ASCAwaiverRequest@cms.hhs.gov) for Review and issuance of the CMS decision. The contractor must forward an explanation letter as to why the contractor (MAC)  recommends CMS approval to DTAS with the waiver request. The contractor will be copied on the decision notice DTAS issues to the requestor.   If the contractor does not consider an unusual circumstance to be met, and does not recommend DTAS approval, the contractor must issue a form letter (Exhibit B). As required by the Privacy Act of 1974, letters issued to a provider to announce a waiver decision must be addressed to the organizational name of a provider and not to an individual (whether a sole practitioner, employee, or an owner of the provider organization). The organizational name is generally a corporate name under which the provider is registered as a Medicare provider or that is used to obtain an EIN.  Unusual Circumstances that Require CMS Review: