(Medicare Claims Processing Manual)

When contacted, the RRB SMAC shall:   a. Ask the provider which MAC made and reversed that ASCA denial decision and furnish the provider with information to mail a copy of that letter to the appropriate person at the RRB SMAC;   b. Tell the provider not to begin to submit new paper claims, or resubmit those already denied as submitted on paper, until the provider recei ves a reversal letter (F) from the RRB SMAC; and   c. Update PES accordingly upon receipt of the copy of the reversal letter and trigger release of a new letter F so that the newly submitted and resubmitted RR paper claims from that provider can be processe d.  90.7.4 - Number of ASCA Enforcement Reviews to be Conducted by the RRB SMAC  (Rev. 2965, Issued: 05- 23-14, Effective: 07- 25-14, Implementation: 07- 25-14)  Due to the impact of ASCA review decisions made by A/B MACs (B), it would not be reasonable to require that the RRB SMAC issue new ASCA review letters for 20 percent of the providers who send them paper bills annually without giving the RRB SMAC some credit for the additional effort expended as result of the PES -SuperPES -quarterly paper claim submit ters reports reviews the RMC is required to conduct.  It takes the RRB SMAC longer to identify providers that should be sent letters to initiate a new ASCA review and in some cases, the cross checks performed by the RRB SMAC result in disqualification of a  provider for selection for a new ASCA Enforcement Review.  To adjust for this, the RRB SMAC annual ASCA review target is to review the records of 20 percent of those providers who submit paper claims as indicated in the MCS quarterly paper claim submitter s reports, and not to necessarily initiate a new ASCA review of 20 percent of the providers that send them paper claims annually.   To compute this 20 percent, the total number of providers for whom reviews are to be conducted shall be computed as directed in 90.5.3.  To gauge the number to be reviewed during a single quarter in the same FY prior to production of the fourth quarterly report for that FY, the RRB SMAC shall multiply the total of providers who submitted paper bills in the most recent quarterly  report by 0.2 (20 percent), and then multiply again by .25.  The number of reviews to be initiated during the fourth quarter shall be computed by subtracting the total reviews identified as conducted for the first three quarters of the FY from the total n umber of reviews targeted for the FY as a whole; the difference in the totals is the number of reviews to be started during the fourth quarter.  For purposes of the monthly ASCA review report submitted to DTASdata.info prior to the fourth quarter of a FY, the total number of providers in the MCS most recent quarterly paper claim submitters report shall be entered in the eligible providers field.   The total number of providers in that quarterly report for whom ASCA review letters are actually issued to begin reviews plus those for whom a decision is made that a new review is not warranted at that time due to an ASCA review action taken by another Medicare contractor shall be entered in the Initial Review Letters Issued  for Report Period field of the monthly DTASdata .info report.  CMS realizes that an initial review letter will not actually have been issued by the RRB SMAC to each provider in this second situation, but the RRB SMAC review of ASCA data in SuperPES for those providers selected from the MCS quarterly paper claim submitters report which result in decisions not to initiate new reviews will be considered as equivalent to initiation of a new review by CMS for comparison purposes with A/B MACs (B) and to determi ne if the annual 20 percent target has been reached by the RRB SMAC .  The number of ASCA reviews completed total to be entered in the monthly report shall equal the number of ASCA reviews completed during the reporting period that were initiated with an ASCA review letter plus the number of new ASCA reviews that were determined not to be warranted that month as result of review of ASCA information in SuperPES that same month.  For the fourth quarter of the FY, the total number of providers as computed for the FY who are eligible for review, i.e., the total who submitted paper claims in each of the quarterly ASCA reports for the FY divided by four, shall be entered in the DTASdata.info monthly report as the number of Eligible Providers.  The RRB SMAC shall  follow the direction in the prior paragraph to calculate the number of Initial Review Letters Issued for Report Period and the Reviews Completed totals to be entered in those fields of the DTASdata.info reports for the months in that final quarter.  T he remaining fields of the monthly ASCA reports are to be completed by the RRB SMAC according to the existing completion instructions for that report which were previously issued to the Medicare contractors.   90.7.5 - RRB SMAC Information in ASCA Enforceme nt Review Letters  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  The letters that apply to ASCA Enforcement Reviews at the end of this chapter did not originally refer to application of decisions made by an A/B MAC (B) to a provider when billing the RRB SMAC.  These letters have now been modified to note that an ASCA Enforcement Review made by one Medicare MAC that a provider does not qualify to submit claims on paper also applies to that same provider when billing other Medic are MACs, including the RRB SMAC.  Two letters (G and H) have been added specifically for RRB SMAC use.  Letters G and H may not be sent by and do not apply to any contractor other than the RRB SMAC.  The ASCA regulation indicated that denial of claims bec ause they were not submitted to Medicare electronically would be applied on a prospective basis.  Ninety days is being allowed prior to denial in letters G and H to allow time for those providers that do not have software for submission of electronic claim s to the RRB SMAC to obtain that software from their vendor.  Addition of a RRB SMAC module to some commercial electronic claim submission software can reportedly be expensive.  As result, wording has also been included in the letters concerning the Medica re free billing software.   The cost charged by a commercial software vendor for a module to enable claims to be submitted to the RRB SMAC electronically is not a valid basis for waiver of the requirement that a provider submit their claims to the RMC electronically.  The RRB SMAC shall encourage a provider who may mention cost to use the RMCs free billing software if this would be a more cost effective method of electronic submission of their claims to the RRB SMAC.  The provider shall use either the comme rcial software of their choice or the Medicare free billing software and shall begin to submit their claims to the RRB SMAC electronically if they wish to continue to be paid for services furnished to RR Medicare beneficiaries.   The ASCA Enforcement Review  letters now refer to an ASCA electronic claim submission requirement made by one MAC as applying to all MACs because that is actually how ASCA decisions are to be applied.  CMS has not enforced this across the board due to the lack of a vehicle for sharin g decisions across contractor lines, other than in the case of the RRB SMAC.  If a vehicle becomes available to do this in the future for contractors other than the RRB SMAC, CMS will begin to require that this be done.  Sharing of these decisions across t he board would require coordination to eliminate the possibility that more than one contractor could conduct reviews of the same provider at the same time so this issue would also need to be addressed in any subsequent change request issued for this purpos e.  90.7.6 - RRB SMAC Costs Related to Use of ASCA Review Information in SuperPES Files  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Costs for FY 2009 and later for ASCA review expenses as delineated are to be included in the annual operations budget request submitted by the RRB SMAC.   Exhibits of Form Letters  (Rev. 2965, Issued: 05- 23-14, Effective: 07- 25-14, Implementation: 07- 25-14)  Exhibit A - Response to a non - unusual circumstance 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:  Electronic Claim Submission Waiver Request  You recently submitted a re quest for waiver of the Administrative Simplification and Compliance Act (ASCA) requirement that claims be submitted electronically to be considered for Medicare payment.  Providers are to self -assess to determine if they meet the criteria to qualify for a  waiver.  A request for waiver is to be submitted to a Medicare contractor only when an unusual circumstance, as indicated in b, c or d below applies.  Medicare will not issue a written waiver determination unless b, c or d applies.   ASCA prohibits payment of service and supply claims submitted to Medicare on paper, except in limited situations that apply either 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 p roviders -To qualify, a provider required to use a CMS -1450 form 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 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 an agreement in place with a Medicare contractor that commits them to electronic submission of mass immunization cla ims;  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 Administrative Contractors (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.  This exception applies only while electricity or electronic communication is d isrupted; 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 to require claims affected by the circumstance to be submitted electronically.  Exa mples of unusual circumstances include:   a. Periods when a MAC's claim system might temporarily reject a particular type of electronically submitted claim, pending system modifications (individual MACs notify their providers of these situations if they appl y);  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 m edical 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.   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