(Medicare Claims Processing Manual)

If there is more than one entry in SuperPES for the same provider, perhaps as result of the providers submission of claims to more than one Medicare contractor, the RRB SMAC shall compare each of those entries that contains an ASCA decision and enter that decision and that effective date in PES that is the most negative in terms of the number of paper claims that would be submitted to the  RMC as result of entry of that decision and date.  The RRB SMAC has discretion to determine which set of ASCA information is the most negative overall.   90.7.1 - RRB SMAC Entry of ASCA Enforcement Review Decisions and EDI Enrollment Information from Other  Medicare Contractors into PES (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  To take advantage of the information being added to SuperPES, the RRB SMAC shall do the following:    When using SuperPES to establish an initial rec ord in PES for a provider-- If available in SuperPES, the RRB SMAC shall copy any ASCA review result information and the providers ZIP Code, (extended if available), as well as those data elements that would have been copied in the past, and include that i nformation in PES.  If there is an NE entry in the ASCA review decision field, the RRB SMAC shall manually issue letter G to the provider to notify the provider that paper claims submitted to the RRB SMAC beginning on the 91st day after the date of the let ter will be denied unless the provider can establish eligibility for one of the ASCA exceptions.  See information later in this section on use of ASCA decision codes in selection of providers to be sent an ASCA Enforcement review letter.  If no evidence ha s been received by the 45th day after the date of that letter, MCS shall trigger release of letter D.  MCS shall trigger release of letter E and begin denying paper claims on the 91st day after the date of letter G as if a normal ASCA review was being cond ucted, unless the provider submits documentation that results in cancellation of the denial by the RRB SMAC.    When a provider for whom a PES record was previously established is selected from the shared systems quarterly paper claim submitters report to i nitiate a new ASCA Enforcement Review -- The RRB SMAC shall look up each selected provider that has been tentatively selected for an ASCA review in the most recent SuperPES file to see if a record can be located based upon the information the RRB SMAC has a vailable for that provider.  When able to locate a record, the RRB SMAC shall add any ASCA review results from another Medicare contractor for that provider and the ZIP Code (extended if available) for that provider to PES.  An NE decision shall be conve rted to NR.  See information later in this section on use of ASCA decision codes in selection of providers to be sent an ASCA Enforcement Review letter.  The RRB SMAC will use the shared systems quarterly report to trigger release of letter H to notify the provider that paper claims they submit beginning on the 91st day after the date of the letter will be denied.  If no response is received after 45 days, MCS shall trigger release of letter D.  If no response is received to letter D, or there is a respo nse but it will not result in a decision to allow the provider to continue to submit paper claims, MCS shall trigger release of letter E and begin denying paper claims submitted following the regular procedures for an ASCA Enforcement Review.    If the RRB S MAC  learns that a provider that sends paper claims to the RRB SMAC and sends electronic claims to one or more other Medicare contractors -When this information comes to the attention of the RRB SMAC as result of an action other than establishment of an init ial record in PES or selection of a provider for review from the quarterly ASCA report, the RRB SMAC shall check the providers record in SuperPES and in the last quarterly paper claim submitters report received from MCS.  If there are no ASCA Enforcement Review results in SuperPES that would preclude initiation of an ASCA Enforcement Review (see 90.7.2), the RRB SMAC shall use the quarterly report to trigger release of letter H.  MCS shall trigger letters D and E as appropriate in a regular ASCA Enforceme nt Review unless the RRB SMAC cancels denial of the paper claims because the provider responded and was able to establish grounds for continued submission of paper claims to the RRB SMAC.  If the RRB SMAC has already initiated all reviews targeted for that  quarter, the RRB SMAC may initiate this review as part of the next quarters reviews.   If the ASCA information in SuperPES  for a provider indicate that the provider was determined to be eligible for continued submission of paper claims as result of an ASCA review, the RRB SMAC shall enter that ASCA exception/waiver decision in PES for future reference.  If a provider alleges that contrary to a NE ASCA review determination in SuperPES, they do not submit Medicare claims to any MAC electronically and that provider furnishes a letter from another MAC that indicates an ASCA exception/waiver determination that is not yet reflected in SuperPES, the RRB SMAC is to enter the appropriate ASCA decision code in PES for the provider and shall not deny the providers paper claims for ASCA purposes.   In the absence of such a letter however, the RRB SMAC is to assume that providers that have an NE entry in SuperPES do submit electronic claims to at least one other MAC, do submit 10 or more claims electronically to Medicare overall and can also submit claims to the RRB SMAC electronically.  The RRB SMAC is to use the most recent MCS quarterly p aper claim submitters report, or if all reviews targeted for that quarter have already been initiated, the next quarterly paper claim submitters report received to trigger release of letter H in that situation.  MCS shall trigger letters D and E and begin denial of that providers paper claims on the 91st day unless the RMC delays or cancels the denial action.   90.7.2 - Selection of Providers to be Sent Initial Letters for the RRB SMAC to Begin an ASCA Enforcement Review  (Rev. 2803, Issued: 10- 28-13, Effect ive: 09- 17-13, Implementation: 09- 17-13)  If a provider is being considered for an ASCA review, the RRB SMAC shall check the latest SuperPES file to determine if another MAC has conducted an ASCA Enforcement Review.  If there is an ASCA decision in SuperPE S that was made later than any ASCA decision already posted in PES, the RRB SMAC shall update the information in PES and determine based upon the new information whether appropriate for them to initiate a new ASCA review of that provider.  The RRB SMAC sha ll not send a letter to a provider to begin an ASCA Enforcement Review if:   o SuperPES contains a SM decision for the provider that is less than two years old;  o SuperPES  contains the date an enforcement review began but does not contain a decision and at least 121 days have not elapsed since the date the review began (this signifies another contractor has an ASCA review underway for that provider); or   o SuperPES contains a  UC decision and fewer than 6 months have elapsed since the date of that decision.  When there is an NE decision in SuperPES  with a past date, the RRB SMAC  shall use a MCS quarterly paper claim submitters report to trigger release of letter H to that provider to notify them that their paper claims will begin to be denied on the 91st day after the date of that letter.   The RRB SMAC  shall use a MCS quarterly paper claim submitters report to trigger release of letter C to a provider to initiate an ASCA Enforcement Review if:   a. There are no SuperPES ASCA field entries for a provider;   b. There is a UC decision in SuperPES and more than 6 months have elapsed since the date of that decision;   c. SuperPES contains the date an enforcement review began but does not contain a decision and more than 121 days have elapsed since the date the review began;   d. There is a SM decision in  SuperPES, more than two years have elapsed since the date of that decision, and the number of paper claims that provider submitted to the RRB SMAC as indicated in the most recent ASCA quarterly report is high enough to have resulted in this provider being  selected for initiation of an ASCA review in the event that there had not been any ASCA field entries in SuperPES for this provider; or   e. There is a WA decision in SuperPES and enough paper claims were submitted to the RMC as indicated by the MCS quar terly paper claim submitters report to have resulted in this provider being selected for initiation of an ASCA review in the event that there had not been any ASCA field entries in SuperPES for this provider.   Use of ASCA review information from SuperPES m ay result in denial of paper claims submitted by some providers who had been previously told by the RRB SMAC that they could submit their claims on paper as they submit fewer than 10 to the RRB SMAC per month.  This situation is addressed in letter H.  Alt hough it would have been preferable to share ASCA paper claim denial decisions with the RRB SMAC when ASCA Enforcement Reviews first began, that was not possible at the time.  Addition of information about ASCA Enforcement Review results to SuperPES files now makes application of these decisions by the RRB SMAC possible.  90.7.3 - Subsequent Reversal of Decision that a Provider is Not Eligible to Submit Paper Claims by an A/B MAC (B)  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  MACs often begin to deny paper claims because a provider failed to respond to the initial and second request ASCA Enforcement Review letters (see exhibit letters D, G, H and E at the end of this chapter).  Providers sometimes furnish that evidence after denial of their paper claims begins.  If the evidence shows that the provider actually qualified for one or more exception criteria retroactively to the date when denial of their paper claims was effective, the Medicare contractor shall replace th e paper claim denial decision (NE) in the providers file with a new decision based upon the submitted evidence.  If the provider then resubmits the claims to that contractor that were denied as submitted on paper following receipt of letter F from that co ntractor, they will be reprocessed and paid if they otherwise meet Medicare requirements.   In this situation, a paper claim denial decision transmitted to the RRB SMAC one week may be replaced by a different decision in a subsequent weeks SuperPES file.  It is not possible to automatically post the revised decision in the RR PES file based on this change in SuperPES however, and A/B MACS (B) do not have access to records that indicate whether particular providers bill the RRB SMAC and which might allow the m to notify the RRB SMAC directly of such a reversal.  In this situation, a provider who also bills the RRB SMAC and who has been notified that the paper claims sent to the RRB SMAC will be or have started to be denied based on the ASCA electronic claim submission requirement would be expected to contact the RRB SMAC to report the reversal of the decision made by the non- RR Medicare contractor.   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)