(Medicare Claims Processing Manual)

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;   9. Claims from providers experiencing a disruption in their electri city 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 disrupted; 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 preclude s 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.  Examples of unusual circumstances include:   a. Periods when a Medi care contractors claim system might temporarily reject a particular type of electronically submitted claim, pending system modifications (individual Medicare claims processing contractors notify their providers of these situations if they apply);   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 medical  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.  If you intend to continue to submit paper claims, please re spond within 30 calendar days of the date of this letter to indicate which of the above situations is your basis for continuing submission of paper claims to us.  Include with your response, evidence to establish that you qualify for waiver of the electronic filing requirement under that situation.  For instance, if you are a small provider, evidence might consist of copies of payroll records for all of your employees for (specify the start and end dates of the calendar quarter for which the review is being  conducted) that list the number of hours each worked during that quarter.  If you are a dentist, evidence might be a copy of your license.   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 this 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 office 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 tha t 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 us, we will begin to deny all paper claims you submit to us effective with the 91st calen dar 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 .  You have a number of alternatives to consider for electronic submission of your claims to Medicare.  Commercial software, and billing agent and clearinghouse services are available on the open market that can be used to bill us as well as other payers.  Please visit (contractor shall insert the URL for vendor information) to see a list of HIPAA -compliant vendor services available in your state.  Some providers have reported that their software vendor or clearinghouse charges a substantial additional amount to allow a provider to submit Railroad Medicare claims electronically.  Please contact this office if this situation also applies in your case.  This office can supply you with free billing software for submission of Medicare claims.  See (contractor sh all insert the URL where information is located on their free billing software, the amount of any handling charge for issuance, how to obtain further information, and the EDI Enrollment Agreement which will need to be completed for further information on e nrollment for use of EDI, use of free billing software or other EDI information.         Sincerely,  Contractor Name   Exhibit H - Notice from the Railroad 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  (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   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 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.  Paper claims will be denied if submitted by entities determined to be in violation of the statute or this rule.  ASCA did not differentiate among Medicare A dministrative Contractors (MACs) or between Railroad and non -Railroad Medicare for application of the electronic claim submission requirement or exceptions to that requirement.  We recently discovered that you have been submitting more than 10 Medicare claims per month on average to one or more other MACs and/or submitting claims to another MAC electronically.  Unless you have been issued a letter by one or more MACs granting you a waiver of more than 90 days from the ASCA requirement for electronic subm ission of your claims, or are now able to establish that you do meet one or more of the criteria for waiver of this ASCA requirement, you are also required to submit your claims to us for Railroad beneficiaries electronically.  If you have such a letter, o r evidence that you do now qualify for a waiver of this ASCA requirement, please forward a copy of that letter or evidence to this office to enable us to update our records and permit you to continue to submit claims to us on paper if you choose.   ASCA pro hibits submission of paper claims except in limited situations that may apply 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 providers --To qualify, a provider requi red to use the Form CMS -1450 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 demonstrat ion 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 MAC that commits them to electronic submission of mass immunization claims;  5. Claims sent to Medicare when more than o ne 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 MACS including the Railroad Board Specialty 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 disrupted; 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.  Examples 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 Medicare claims processing contractors notify their providers of these situations if they apply);   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 medical record or other claim attachment cann ot 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.  It is possible that you may previously have contacted this office or had an ASCA Enforcement Revi ew conducted by this office and were informed that you are eligible to continue submitting paper claims to this office since you submit fewer than 10 Medicare claims to us per month.  Until recently, we did not have access to ASCA review information from other MACs that could be used to determine whether you should be submitting your claims to us electronically.  As we do now have access to this type of information from other MACs, we are required to apply that information to you and to other providers that  submit paper claims to this office.   As you may not have been notified that an ASCA electronic claim submission requirement that applies to another MAC also affects your submission of paper claims for Railroad Medicare beneficiaries, we will not begin to deny your paper claims until the 91st day after the date of this letter.  This will allow you time to make changes as needed so you can begin to submit your claims to us electronically by the 91st day.   In the event your situation changes and you feel that  you do meet one or more of the criteria for an exception from the ASCA electronic claim submission requirement, you should recontact us and any other MAC that made a determination that you do not currently qualify for an exception.  If determined that you do in fact qualify for an exception at that point, you would have the option to again begin to submit some or all of your Medicare claims on paper.  The type of exception criteria you meet will determine if the exception applies to only certain types of y our claims, all of your claims or applies only for a temporary period.  That would be addressed in the decision notice you would be sent.   Some providers have reported that their software vendor or clearinghouse charges a substantial amount to submit Railr oad Medicare claims electronically.  Please contact this office if this situation also applies in your case.  This office can supply you with free billing software for submission of Medicare claims.  See (contractor shall insert the URL where information i s located on their free billing software, the amount of any handling charge for issuance, how to obtain further information, and the EDI Enrollment Agreement which will need to be completed for further information on enrollment for use of EDI, use of free billing software or other EDI information.  Sincerely,