(Medicare Claims Processing Manual)

d. Other circumstances documented by a provider, generally in rare cases, where a provider can establish that, due to conditions outside of the providers control, it would be against equity and good conscience for CMS to enforce the electronic claim submission requirement.   The request you submitted did not include information to establish that situation b, c or d applies.  You are expected to self -assess to determine if one of the other exceptions or unusual circumstances applies.  If your self -assessment indicates that you do meet one of those situations, you are automatically  waived from the electronic claim submission requirement while the circumstance is in effect.  Your MAC will monitor your compliance with this ASCA requirement on a post -payment basis.  If your self- assessment does not indicate that exception or waiver criteria apply as listed above, you shall submit your claims to Medicare electronically.  This applies to every MAC to which you submit claims, including the contractor responsible for proc essing of Railroad Medicare claims.  The Common Electronic Data Interchange (CEDI) contractor can supply you with free billing software for submission of Medicare DME claims.  Visit the CEDI Web site at www.ngscedi.com for further information on enrollment for use of EDI, use of free billing software, and other DME EDI information.  There are also commercial billing software, and billing agent and clearinghouse services available on the open market that can be used to bill Medicare as well as other payers and may better meet your needs.  Please visit the CEDI Website (www.ngscedi.com) to see a list of HIPAA -compliant vendor services available to you.   Sincerely,    Contractor Name   Exhibit B - Denial of an unusual cir cumstance waiver request  (Rev. 2965, Issued: 05- 23-14, Effective: 07- 25-14, Implementation: 07- 25-14)  Date:   From:  MAC (Name and address may appear on masthead)   To:   Organizational Name of Provider and Mailing Address   Subject:    Request for Waiver of Electronic Claim Filing Requirement Decision   Your request for waiver of the requirement that Medicare claims be submitted electronically has been denied.  The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submit ted to Medicare on paper, except in limited situations.  Those situations are:   1. Claims submitted by small providers -To qualify, a provider required to use a CMS 1450 form when submitting paper claims shall have fewer than 25 full -time equivalent employe es (FTEs), and a physician, practitioner, or supplier required to use the CMS -1500 form in a current version when submitting claims on paper shall have fewer than 10 FTEs.  A small provider can elect to submit all, some or none of their claims electronical ly;  2. Dental Claims;  3. Claims submitted by participants in a Medicare demonstration project for services or items covered under that demonstration project, when paper claim filing is required as result of the inability of the HIPAA claim implementation  guide to handle data essential for that demonstration;   4. Roster claims for mass immunizations, such as flu or pneumonia injections --Paper roster bills cover multiple beneficiaries on the same claim.  This exception applies to providers who do not have a n agreement in place with a Medicare contractor that commits them to electronic submission of mass immunization claims;   5. Claims sent to Medicare when more than one other insurer was liable for payment prior to Medicare;   6. Claims submitted by providers  that rarely treat Medicare patients and that submit fewer than 10 claims a month to Medicare in total (total of all claims sent to all MACs including the RRB Specialty Medicare Administrative Contractor);  7. Claims submitted by beneficiaries;   8. Claims  from providers that only furnish services outside of the United States;   9. Claims from providers experiencing a disruption in their electricity or communication connection that is outside of their control and is expected to last longer than two days.  Th is exception applies only while electricity or electronic communication is disrupted; and   10. Providers that can establish that some other unusual circumstance exists that precludes submission of claims electronically.   The Centers for Medicare & Medicaid Services (CMS) interprets an unusual circumstance to be a temporary or long -term situation outside of a providers control that precludes submission of claims electronically and as result, it would be against equity and good conscience for CMS t o require claims affected by the circumstance to be submitted electronically.  Examples of unusual circumstances include:   a. Periods when a MAC's claim system might temporarily reject a particular type of electronically submitted claim, pending system m odifications (individual MACs notify their providers of these situations if they apply);   b. Documented disability of each employee of a provider prevents use of a computer to enable electronic submission of claims;   c. Entities that can demonstrate that information necessary for adjudication of a type of Medicare claim that does not involve a medical record or other claim attachment cannot be submitted electronically using the claim formats adopted under the Health Insurance Portability and Accountability Act (HIPAA); and   d. Other circumstances documented by a provider, generally in rare cases, where a provider can establish that, due to conditions outside of the providers control, it would be against equity and good conscience for CMS to enforce the elec tronic claim submission requirement.  We have determined that you do not meet any of these criteria for waiver of the ASCA requirement for electronic submission of Medicare claims.  ASCA did not establish an appeal process for waiver denials, but you can r e-apply for an unusual circumstance waiver if your situation changes.  This decision applies to paper claims you may submit to any MAC in the United States, including the RRB Specialty Medicare Administrative Contractor.  As you do not qualify for a waiver of the ASCA electronic claim submission requirement, Medicare will begin to deny paper claims you may submit beginning on the 91st day after the date of this letter.   Waiver applications are only to be submitted to request a waiver if an unusual circum stance applies under b, c or d above. The information submitted with your waiver request did not indicate that circumstance b, c or d any other exception or waiver criteria apply in your case.  If your self -assessment indicates that an exception condition , other than b, c or d is met, you are automatically waived from the electronic claim submission requirement and no request should be submitted to a MAC.  MACs will monitor compliance with the ASCA electronic billing requirements on a post-payment basis.  Paper claims submitted to Medicare that do not meet the exception or unusual circumstance criteria do not qualify for Medicare payment.  The Common Electronic Data Interchange (CEDI) contractor can supply you with free billing software for submission of Me dicare DME claims.  Visit the CEDI Web site at www.ngscedi.com for further information on enrollment for use of EDI, use of free billing software, and other DME EDI information.  There are also commercial billing software, and billing agent and clearinghouse services available on the open market that can be used to bill Medicare as well as other payers and may better meet your needs.  Please visit the CEDI Website (www.ngscedi.com) to see a list of HIPAA-compliant vendor services available to you.     Sincerely,       Contractor Name    Exhibit C - Request for Documentation from Provider Selected for Review to Establish Entitlement to Submit Claims on Paper  (Rev. 2965, Issued: 05- 23-14, Effective: 07-25-14, Implementation: 07-25-14)  Date:   From:  MAC (Name and address may appear on masthead)   To: Organizational Name of Provider and Mailing Address  Subject:  Review of Paper Claims Submission Practices   A large number of paper claims were submitted under your provider number(s) during the last calendar quarter.  Section 3 of the Administrative Simplification Compliance Act, P.L. 107-105 (ASCA), and the implementing regulation at 42 CFR 424.32, require that all initial claims for reimbursement from Medicare be submitted electronically with limited exceptions.  The ASCA amendment to  1862(a) of the Social Security Act prescribes that no payment may be made under Part A or Part B of the Medicare Program for any expenses incurred for items or services for which a claim is  submitted in a non-electronic form.  This also applies to payments made for beneficiaries who qualify for Medicare based upon their employment in the railroad industry.  ASCA prohibits submission of paper claims except in limited situations that may apply  to all of a providers claims, only to specified types of claims or for a limited period as indicated below:  1. Claims submitted by small providers -- To qualify, a provider required to use the Form CMS 1450 when submitting claims on paper shall have fewer than 25 full- time equivalent employees (FTEs).  A physician, practitioner, or supplier required to use a CMS -1500 form in a current version when submitting claims on paper shall have fewer than 10 FTEs.  A small provider can elect to submit all, some or none of their claims electronically;   2. Dental claims;  3. Claims submitted by participants in a Medicare demonstration project for services or items covered under that demonstration project when paper claim filing is required as result of the inability o f the HIPAA claim implementation guide to handle data essential for that demonstration;  4. Roster claims for mass immunizations, such as flu or pneumonia injections --Paper roster bills cover multiple beneficiaries on the same claim.  This exception applie s to providers who do not have an agreement in place with a Medicare contractor that commits them to electronic submission of mass immunization claims;   5. Claims sent to Medicare when more than one other insurer was liable for payment prior to Medicare;   6. Claims submitted by providers that rarely treat Medicare patients and that submit fewer than 10 claims a month to Medicare in total (total of all claims sent to all Medicare contractors including the RRB Specialty Medicare Administrative Contractor ;   7. Claims submitted by beneficiaries;  8. Claims from providers that only furnish services outside of the United States;   9. Claims from providers experiencing a disruption in their electricity or communication connection that is outside of their control and is expected to last longer than two days.  This exception applies only while electricity or electronic communication is disrupted; and   10. Providers that can establish that some other unusual circumstance exists that precludes submission of claims ele ctronically.   The Centers for Medicare & Medicaid Services (CMS) interprets an unusual circumstance to be a temporary or long -term situation outside of a providers control that precludes submission of claims electronically and as result, it would be aga inst equity and good conscience for CMS to require claims affected by the circumstance to be submitted electronically.  Examples of unusual circumstances include:   a. Periods when a MAC's claim system might temporarily reject a particular type of electro nically submitted claim, pending system modifications (individual MACs notify their providers of these situations if they apply);   b. Documented disability of each employee of a provider prevents use of a computer to enable electronic submission of claims;   c. Entities that can demonstrate that information necessary for adjudication of a type of Medicare claim that does not involve a medical record or other claim attachment cannot be submitted electronically using the claim formats adopted under the Health Insurance Portability and Accountability Act (HIPAA); and   d. Other circumstances documented by a provider, generally in rare cases, where a provider can establish that, due to conditions outside of the providers control, it would be against equity and good conscience for CMS to enforce the electronic claim submission requirement.  If you intend to continue to submit paper claims, please respond within 30 calendar days of the date of this letter to indicate which of the above situations is your basis for  continuing submission of paper claims to Medicare.  Include with your response, evidence to establish that you qualify for waiver of the electronic filing requirement under that situation.  For instance, if you are a small provider, evidence might consist  of copies of payroll records for all of your employees for (specify the start and end dates of the calendar quarter for which the review is being conducted) that list the number of hours each worked during that quarter.  If you are a dentist, evidence mig ht be a copy of your license.   If you are in a Medicare demonstration project, evidence might be a copy of your notification of acceptance into that demonstration.  If you are a mass immunizer, evidence might be a schedule of immunization locations that indicates the types of immunizations furnished.  If you experienced an extended disruption in communication or electrical services, evidence might consist of a copy of a newspaper clipping addressing the outage.  If the paper claims were submitted because th is office notified you of a system problem preventing submission of these claims electronically, please note that in your response.  If your continuing submission of paper claims is the result of medical restrictions that prevent your staff from submitting  electronic claims, evidence would consist of documentation from providers other than yourself to substantiate the medical conditions. If you obtained an unusual circumstance waiver, evidence would be a copy of your notification to that effect from this of fice or the Centers for Medicare & Medicaid Services.   Providers that received waivers for a specific claim type are still required to submit other claims electronically unless they meet another criterion, e.g., small provider, all staff have a disabling condition that prevents any electronic filing, claims are for dental services, or if they otherwise qualify for a waiver under a situation that applies to all of their claims.