(Medicare Claims Processing Manual)

B. A letter shall also be sent to the provider or supplier explaining the statutory requirement for submitting claims for all services rendered to Medicare beneficiaries.  The letter should explain to the provider or supplier that they are required to enroll with the Medicare program before a claim can be submitted.  Finally the letter should include language explaining the penalties for failure to comply with the mandatory claims submission requirements.  70.8.8.8 - Violations That Are Not Developed For Referral  (Rev. 420, Issued:  12- 30-04, Effective:  01/31/05, Implementation:  01/31/05)   Claim submission violations need not be developed on beneficiary- submitted Form CMS -1490S claims that include approved charges for services performed on or after September 1, 1990 in the following situations:   o Used DME purchases from private sources;   o Cases in which a physician/supplier does not possess information essential for filing a MSP claim.  Assume this is the case if the beneficiary files a MSP claim and encloses the primary insurer's payment determination notice and there is no indication that the service provider was asked to file but refused to do so;   o Services paid under the indirect payment procedure;  o Foreign claims; and  o Other unusual or unique situations that you evaluate on a case -by-case basis.   NOTE:   It is unlikely that knowing, willful, and repeated noncompliance will apply in the above situations.  80 - Carrier and FI Claims Processing Timeliness  (Rev. 1, 10- 01-03) A3-3600, A3- 3600.1, B3 -13306, HO -401, HO -401A, HH -462, B2- 5240.11 Carriers and FIs must establish control records for timely claims processing as described below. 80.1 - Control and Counting Claims  (Rev. 1, 10- 01-03) The carrier or FI will consider claims as received for timely processing purposes from the date of their receipt.  Improperly completed claims that it returns are considered received for timely processing purposes when received again, properly completed.  A.  Provider Billing Via Terminal or Equivalent  If the provider bills via remote terminal with on -site (in the provider) editing or if the carrier or FI otherwise can communicate edit results to it electronically, the carrier or FI establishes a control record when the bill passes its consistency edits. B.  Manual Hardcopy Claim/Bills and Electronic Claim/Bills  The carrier or FI establishes a control record when it enters the initial claim into its system.  The claim is counted for administering timely billing and payment only if it passes carrier or FI edits to the extent a pending record can be established.  The date received is the date the carrier or FI received the claim properly completed, passing all carrier or FI edits, even if entered into its system on a later date.  C.  Bills Returned to Provider If the carrier or FI returns the bill and retains a claim record to minimize data entry cost when returned, the receipt date is corrected when the bill is properly completed and passes carrier or FI edits.  D.  Bills Requiring Medical Information  When a carrier or FI requests medical documentation, it retains the bill as a pending record until it either pays, denies, or rejects (in the case of FIs) it.  Returning cases for review by the PRO is not a request for medical documentation.  Claims that f ail initial carrier or FI edits because required medical reports or other required attachments are not included are also not requests for medical documentation. E.  Adjustment and Cancel Bills  An adjustment request bill is a correction to a claim previously processed.  The carrier or FI establishes a control record for it.  The carrier or FI counts adjustments as received and pending only when they pass carrier or FI edits.  The carrier or FI assigns the date received in its mailroom as the receipt date for hospital and MSP adjustment requests. The carrier or FI counts adjustment bills as processed when no further action by it is required.  The final action taken on the adjustment request bill depends upon the situation.  80.2 - Definition of Clean Claim  (Rev. 1, 10- 01-03) HO- 401.D, A3- 3600.1, B2- 5240.11.A  A clean claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis.  Clean claims must be filed in the timely filing period.  The following bullets are some examples of what are considered clean claims :  Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);  Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).   Claims not approved for payment by CWF within 7 days of the FIs original claim submittal for reasons beyond the carriers, FIs or providers control (e.g., CWF system/communication difficulties);  CWF out -of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;   Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carriers or FIs instructions;   Are developed on a postpayment basis; and,   Have all basic information necessary to adjudicate the claim, and all required supporting documentation 80.2.1 - Receipt Date  (Rev. 273, Issued 08- 13-04, Effective: 07 -01-04, Implementation: 07- 06-04) A3-3600.1- Item 7  The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim).  The receipt date is used to: determine if the claim was timely filed (see 70.3), determine the payment floor for the claim (see 80.2.1.2), determine the payment ceiling on the claim (see 80.2.1.1) and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.  A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date.  A paper claim that is received after 5:00 p.m., or after the contractors routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.  A paper claim is considered as received if it is delivered to the contractors place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractors place of business by its routine close of business time.  If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box sit e. As electronic claim tapes and diskettes that may be submitted by providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt rule also applies to establish the date of receipt of claims submitted on such manually delivered tapes and diskettes.  Electronic claims transmitted directly to a contractor, or to a clearinghouse with which the contractor contracts as its representative for the receipt of its claims, by 5:00 p.m. in the contractors time zone, or by its closing time if it routinely closes  between 4:00 p.m. and 5:00 p.m., must likewise be considered as received on that day even if the contractor does not upload or process the data until a later date.  NOTE:  The differentiation between HIPAA -compliant and HIPAA -non-compliant electronic claim s that is specified in 80.2.1.2 with respect to applying the payment floor, does not apply to establishing date of receipt.  Use the methodology described above to establish the date of receipt for all electronic claims.  Paper and electronic claims that do not meet the basic legibility, format, or completion requirements are not considered as received for claims processing and may be rejected from the claims processing system.  Rejected claims are not considered as received until resubmitted as corrected, complete claims.  The contractor may not use the data entry date, the date of passage of front -end edits, the date the document control number is assigned, or any date other than the actual calendar date of receipt as desc ribed above to establish the official receipt date of a claim.  The following permissive exception applies to establishment of receipt date:  Where its system or hours of operation permit, a contractor may, at its option, classify a paper or electronic claim received between its closing time and midnight, or on a Satur day, Sunday, holiday, or during an emergency closing period as received on the actual calendar date of delivery or receipt.  Unless a contractor closes its place of business early in an isolated situation due to an emergency, the contractors cutoff time f or establishing the receipt date may never be earlier than 4:00 p.m. A contractor may not make system changes, extend its hours of operation, or incur significant additional costs solely to begin to accommodate late receipt of claims if not already equipped to do so. The cutoff time for paper claims may not exceed the cutoff time for electronic claims. However, the cutoff time for electronic claims may exceed the cutoff time for paper claims and, indeed, carriers and FIs are encouraged to use this tool where their syst em and overnight batch run schedules permit.  Likewise, at a carrier or FIs option, it may consider electronic claims received on a weekend or holiday as received on the actual calendar date of receipt, even though paper claims received in a P.O. box on a  weekend or holiday would not be considered received until the next business day.  Where a carrier or FI prepares bills for payment for purchased DME because the $50 tolerance is exceeded (see 40.4.1) it establishes any date consistent with its system processing requirements as the receipt date for the second and succeeding bills.  It uses the date as close to its payment as possible.  80.2.1.1 - Payment Ceiling Standards  (Rev. 454, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05) Payment ceilings were implemented for clean claims received by the carrier or FI on or after April 1, 1987.  Clean claims must be paid or denied within the applicable number of days from their receipt date as follows:  Time Period for Claims Received  Applicable Number of Calendar Days  01-01-93 through 09 -30-93 24 for EMC and  27 for paper claims  10-01-93 and later  30 All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.  Interest must be paid on claims that are not paid within the ceiling period. The count starts on the day after the receipt date and it ends on the date payment is made.  For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.  The RAPs submitted by home health agencies under the HH PPS (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not Medicare claims as defined under the Social Security Act.  Since they are not considered claims, they (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not subjected to payment ceiling standards and interest payment.  See Chapter 24,  30.2 for definitions of electronic and paper claims for use in application of the Medicare payment floor.  See Chapter 1,  80.2.1.2 for differentiation between electronic claims that comply with the requirements of the standard implementation guides adopted for national use under HIPAA and those submitted electronically using pre -HIPAA formats supported by Medicare.  This HIPAA format differentiation applies to the payment floor, but not to the ceiling.  80.2.1.2 - Payment Floor Standards (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The payment floor date is the earliest day after receipt of the clean claim that payment may be made.   The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.   There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply: