(Medicare Claims Processing Manual)

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.   If you cannot provide acceptable evidence to substantiate that you are eligible under the law to continue to submit paper claims to Medicare, we will begin to deny all paper claims you submit to us effective with the 91st calendar day after the date of this notice.  ASCA did not establish an appeal process for denial of paper claims in this situation, but you may qualify for a waiver at a later date if your situation changes.  Please contact this office if your situation changes. This decision applies to paper claims you may submit to any MAC in the United States, including the Railroa d Retirement Board Specialty Medicare Administrative Contractor.   If in retrospect, you realize that you do not qualify for continued submission of paper claims, you have a number of alternatives to consider for electronic submission of your claims to Medicare.  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  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 (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   Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L. 107 -105 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.   Our records indicate that you are submitting paper claims to Medicare and did not respond to our initial letter requesting evidence to establish that you qualify for submission of paper claims to Medicare.  Nor do we have information available to us that would substantiate that you meet any of the limited exceptions that would permit you to legally submit paper claims to M edicare.   Consequently, as noted in the initial letter as well as in information issued providers when this ASCA requirement was put into effect, any Medicare paper claims you submit more than 90 calendar days from the date of the initial letter requesting  evidence to substantiate your right to submit paper claims will be denied by Medicare.  ASCA did not establish an appeal process for denial of paper claims in this situation, but you may qualify for a waiver at a later date if your situation changes.  Please contact this office if your situation changes.  This decision applies to paper claims you may submit to any Medicare contractor in the United States, including the RRB Specialty Medicare Administrative Contractor.   If you did not respond because you realized that you do not qualify for continued submission of paper claims, you have a number of alternatives to consider for electronic submission of your claims to Medicare.  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 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.  (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   Section 3 of the Administrative Simplification Compliance Act, Pub.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.   We have reviewed your response to our letter requesting that you submit evidence to substantiate that you qualify for submission of paper claims under one of the exception criteria listed in that letter.  Upon review, we determined that you do not meet the paper claims waiver/exception criteria as stated in our prior letter.  ASCA did not establish an appeal process for denial of paper claims in this situation, but you may qualify for a waiver at a later date if your situation changes.  Please contact this office if such a change in your situation occurs.  This decision applies to paper claims you may submit to any Medicare contractor in the United States, including the RRB Specialty Medicare Administrative Contractor.   Consequently, any Medicare paper claims you submit on or after the 91st calendar day from the date of the letter requesting evidence of your eligibility to continue to submit paper claims will be denied by Medicare.   You have a number of alternatives to consider for electronic submission of your claims to Medicare.  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 F - Notice that determination reached that the provider is eligible to submit paper claims.  (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 Claim Submission Practices   Thank you for your response to our previous letter regarding the prohibition against the submission of paper claims to Medicare.  Based on the information you supplied, we agree that you meet one or more exception criteria to the requirements in 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L.107 -105, and the implementing regulation at 42 CFR 424.32, that require that all initial claims for reimbursement from Medicare be submitted electronically, with limited exceptions.   If your situation changes to the point where you no longer meet at least one of the criteria, you will be required to begin submission of your claims electronically by the 91st calendar day after that change in your status.  Although you are not required to submit claims electronically at the present time, you are encouraged to do so.  The Common Electronic Data Intercha nge (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.  P lease visit the CEDI Website (www.ngscedi.com) to see a list of HIPAA -compliant vendor services available to you.  Sincerely,   Contractor Name   Exhibit G - Notice from the Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) to a Provider that Has Just Begun to Submit Claims that Paper Claims Submitted by that Provider Will be Denied  (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: Organ izational Name of Provider and Mailing Address  Subject:  Denial of Paper Claim Submission Practices   You recently began to treat one or more Railroad Medicare beneficiaries and began to submit claims to us for the first time.  In the process of establishin g a record in our files to indicate that you are eligible to submit Medicare claims, we obtained a copy of your non-RR Medicare enrollment information.  That record indicates that you are required to submit your Medicare claims electronically to at least one other Medicare Administrative Contractor and does not indicate that you were issued a waiver to permit submission of paper Medicare claims.  Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L.107- 105, and the implementing regula tion 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 Act prescribes that no payment may be made under Part A or Part B of the M edicare Program for any expenses incurred for items or services for which a claim is submitted in a non -electronic form.   ASCA did not differentiate among Medicare contractors or between Railroad and non-Railroad Medicare for application of the electronic claim submission requirement or exceptions to that requirement.  As result, we will begin to deny any paper claims you submit to us for Railroad Medicare beneficiaries unless you are able to establish that you meet one or more of the following exceptions to this ASCA requirement:  1. Claims submitted by small providers -- To qualify, 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 full -time equivalent employ ees (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 claims;   5. Claims sent to Medicare when more th an 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;