(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 24  General  EDI and EDI Support Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare Claims   Table of Contents (Rev. 11427, 05-20-22)  Transmittals for Chapter 24   10 - Introduction to Electronic Data Interchange (EDI) for Medicare Fee For Services (FFS)  10.1 - Requirement for EDI  10.2 - Audience for this Chapter  10.3 - Scope of this Chapter  10.4 - Acronyms and Definitions  20 - General EDI  20.1 - Legislative Background  20.2 - The America Reinvestment and Recovery Act (ARRA)  20.3 - HIPAA and ARRA on Security and Privacy  20.4 - Administrative Simplification and Compliance Act (ASCA)  30 - EDI Enrollment and Registration (AKA Trading Partner Agreements)  30.1 - EDI Enrollment  30.2 - New Enrollments and Maintenance of Existing Enrollments  30.3 - Submitter Number  30.4 - Electronic Remittance Advice (ERA) Enrollment Form  40 - Medicare FFS EDI Users Roles and Responsibilities in an EDI Environment  40.1 - Centers for Medicare and Medicaid Services - Medicare Fee- For-Service  40.1.1 - HIPAA Transaction Standards as  Designated by CMS  40.1.2 - Transactions Used in the Acknowledgment of Receipt of Inbound Claims  40.1.3 - Change Request (CR) to Communicate Policy  40.2 - Medicare FFS Contractors (A/B MAC, DME MAC, CEDI)  40.2.1 - Certification Test Program and Annual Recertification Activities  40.2.2 - Security Requirements  40.2.2.1 - A/B MACs, DME MACs, and CEDI Data Security and Confidentiality Requirements 40.2.2.2 -  A/B MAC, DME MACs and CEDI Audit Trails  40.2.2.3 -  Security -Related Requirements for A/B MACs, and CEDI Arrangements With Clearinghouses and Billing Services  40.2.2.4 -  Release of Medicare Data  40.2.2.5 -  EDI Enrollment and EDI Claim Record Retention  40.2.3 -  General EDI Outreach Activities  40.2.3.1 -  A/B MAC and DME MAC Analysis of Internal Information  40.2.3.2 -  Contact With New Providers   40.2.3.3 -  Production and Distribution of Information to Increase Use of EDI  40.2.3.4 -  Production and Distribution of Material to Market EDI  40.2.4 -  Trading Partner Management  40.2.4.1 -  User Guidelines  40.2.4.2 -  Technical Assistance to EDI Trading Partners  40.2.4.3 -  Training C ontent and Frequency  40.2.4.4 -  Prohibition Against Requiring Use of Proprietary Software or DDE  40.2.4.5 -  Free Claim Submission Software  40.2.4.6 -  Newsletters/Bulletin Board/Internet Publication of EDI Information  40.2.4.7 -  Provider Guidelines for Choosing a Vendor  40.2.4.7.1 -   Determining Goals/Requirements  40.2.4.7.2 -  Vendor Selection  40.2.4.7.3 -  Evaluating Proposals  40.2.4.7.4 -  Negotiating With Vendors  40.2.5 -  Provision of EDI User Guidelines  40.2.6 -  Provision and Maintenance of a Directory of Billing Software Vendors and Clearinghouses  40.2.7 -  Operating Rules for Electronic Transactions  40.3 -  Trading Partners  50 - Technical Requirements  50.1 -  Telecommunications, Internet and Dial -up 50.1.1 -  System Availability  50.1.2 -  Media  50.1.3 -  Telecommunications and Transmission Protocols  50.1.4 -  Toll -Free Service  50.2 -  Translators  50.3 -  Common Edits and Enhancements Module (CEM) -  General Description Across All Versions  50.3.1 -  Claim Numbering  50.3.2 -  Receipt Control and Balancing  50.3.3 -  Acknowledgements  50.3.3.1 -  Outbound File Compliance Check  50.3.4 -  Common Edits and Enhancement Module (CEM) Code Sets Requirements  50.3.5 -  Handling of Poorly Formed/Invalid Flat Files for a 277CA  50.4 -  CEDI -  Unique Specifications for DME  50.4.1 -  CEDI Claim Numbering  50.4.2 -  CEDI Receipt Control and Balancing  50.4.3 -  CEDI Acknowledgments for ASC X12 and NCPDP D.O. Transactions  50.5 -  EDI Testing Accuracy  50.5.1 -  Limitation on Testing of Multiple Providers that Use the Same Clearinghouse, Billing Service, or Vendor Software  50.5.2 -  EDI Receiver Testing by A/B MACs and CEDI  50.6 -  Changes in Providers System or Vendors Software and Use of Additional EDI Formats  50.7 -  Delimiters  50.8 -  Nulls  50.9 -  Direct Data Entry (DDE) Screens  50.10 -  Additional Documentation Submitted Via Paperwork (PWK) Segment  50.10.1 -  PWK Background  50.10.2 -  PWK Workflow  50.10.2.1 -  Provider Responsibility  50.10.2.2 -  Contractor Responsibility  60 - EDI Edit Requirements  60.1 -  A/B MACs, and CEDI Edit Requirements  60.2 -  Key Shop a nd Optical Character Recognition  60.2.1 -  Claim Key Shop and Optical Character Recognition (OCR)/Image Character Recognition (ICR) Mapping to ASC X12 Based Flat File  60.2.2 -  Key Shop and Image Processing  60.3 -  COB Trading Partner and Contractor Crossover Claim Requirements  60.4 -  Remittance Advice and Standard Paper Remittances  60.5 -  Payments  60.5.1 -  Payment Floor Requirement  60.5.2 -  Alternative to EFT  60.5.3 -  Electronic Funds Transfer (EFT)  60.5.4 -  Tri-Partite Bank Agreement  60.6 -  Health Care Provider Taxonomy Code (HPTC) Requirements  70 - CMS Defined File Formats  70.1 -  General HIPAA EDI Requirements  70.2 -  National Council for Pr escription Drug Program (NCPDP) Claim Requirements  80 - Electronic Data Interchange (EDI) Reporting Requirements  80.1 -  Contractor Monthly Status Reporting  80.2 -  Common Edits and Enhancement Module (CEM) Reporting  80.3 -  Common Electronic Data Interchange (CEDI) Reporting  80.4 -  HIPAA Transition Reporting  80.5 -  Administrative Simplification and Complian ce Act (ASCA) Reporting  90 - Mandatory Electronic Submission of Medicare Claims  90.1 -  Small Providers and Full -Time Equivalent Employee Self -Assessments  90.2 -  Exceptions  90.3 -  Unusual Circumstance Waivers  90.3.1 -  Unusual Circumstance Waivers Subject to Provider Self -Assessment  90.3.2 -  Unusual Circumstances Waivers Subject to a Contractor Evaluat ion for CMS Decision  90.4 -  Electronic and Paper Claims Implications of Mandatory Electronic Submission  90.5 -  Enforcement  90.5.1 -  FISS Role in ASCA Enforcement  90.5.2 -  MCS & VMS Roles in ASCA Enforcement  90.5.3 -  Contractor Roles in ASCA Reviews  90.5.4 -  Submission of Claims that May Always be Submitted on Paper by Providers Not Otherwise Eligible to Submit Paper Claims   90.6 -  Provider Education  90.7 -  Application of Electronic Data Interchange Enrollment Information and ASCA Enforcement Review Decisions from Other Medicare Contractors to  the Same Providers When They Bill the Railroad Retirement Board Specialty MAC (SMAC)  90.7.1 -  RMC Entry of ASCA Enforcement Review Decisions and EDI Enrollment Information from Other Medicare Contractors into PES  90.7.2 -  Selection of Providers to be Sent Initial Letters for the RMC to Begin an ASCA Enforcement Review  90.7.3 -  Subsequent Reversal of Decision that a Provider is Not Eligible to Submit Paper Claims by a Non -RR Medicare Contractor  90.7.4 -  Number of ASCA Enforcement Reviews to be Conducted by the RMC  90.7.5 -  RMC Information in ASCA Enforcement Review Letters  90.7.6 -  RMC Costs R elated to Use of ASCA Review Information in SuperPES Files  Exhibits of Form Letters  Exhibit A -  Response to a non-  unusual circumstance waiver request  Exhibit B -  Denial of an unusual circumstance waiver request  Exhibit C -  Request for Documentation from Provider Selected for Review to Establish Entitlement to Submit Claims on Paper  Exhibit D -  Notice that paper claims will be denied effective with the 91st calendar day after the original letter as result of non- response to that letter  Exhibit E -  Notice that paper claims will be denied effective with the 91st calendar day after the original letter as result of determination that the provider is not eligible to submit paper claims.  Exhibit F -  Notice that determination reached that the provider is eligible to submit paper claims.  Exhibit G -  Notice from the Railroad Retirement Board Specialty MAC to a Provider that Has Just Begun to Submit Claims that Paper Claims Submitted by that Provider Will be Denied  Exhibit H -  Notice from the Railr oad Retirement Board Specialty MAC to a Provider with a Pre -Established Record in PES that Paper Claims Will Be Denied as Result of the Requirement that a Provider Submit Claims to One or More Other Medicare Contractors Electronically  10 - Introduction to  Electronic Data Interchange (EDI) for Medicare Fee For Services (FFS)  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  EDI for Medicare FFS is not limited to the submission and processing of claim related transactions, but includes processes such as provider EDI enrollment, beneficiary eligibility, coordination of benefits, as well as security and privacy concerns.  So as not to be duplicative, where EDI is a relevant part of a Medicare business process, it will be indicated here, however, the specifics of the business process will be maintained in its respective IOM chapter or comparable communication venue.   10.1 - Requirement for EDI  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  For a provider, business associate, or other trading partner to engage in EDI with Medicare FFS, it must first establish an EDI agreement with Medicare.   There are two ways to do this:  1) complete and submit paper CMS Form 855, or 2) submit an Internet based application  via the Provider Enrollment, Chain and Ownership System (PECOS) system.  More information on enrolling in the Medicare Program can be found at http://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/MedicareProviderSupEnroll/index.html?redirect=/medicareprovidersupenroll  10.2 - Audience for this Chapter  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  The information contained in this chapter will be of interest to Medicare providers, business associates or other trading partners, as well as others interested in how Medicare has structured its EDI policies.  Other Medicare FFS and CMS partners as well as general audiences may use this as a source of information to determine Medicare FFS EDI practices.  Primarily however, this chapter, and related chapters, are used by Medicare contractors for descriptive guidance t o contractual responsibilities they have to CMS.