evekhm/cms_iom_500 huggingface dataset:
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NOTE :  Shared systems h ave the option to use adjudicated or processed claims, rather than submitted claims, for preparation of the report if that would take less time or resources to prepare.  If using adjudicated or processed claims instead of submitted claims, this must be noted in the report.  B. Identification of Providers to Be Reviewed, Letters to be Issued and Determinations Made A check block or field that can be used to identify those providers being selected for review must appear at the beginning of the data line for each listed provider.  The report produced for the RRB SMAC must permit the RRB SMAC to designate whether letter C or H is to be issued.  The block or field will be completed by the contractors to identify those providers chosen for ASCA review. When an A/B MAC (B) and DME MAC completes that block/field, the shared system will notify the A/B MAC (B) and DME MACs correspondence system by the next business day to release Exhibit letter C (or H in the case of the RRB SMAC) to that provider and will furnish the start and end date of the quarter on which the review is based (for contractor entry in the paragraph that follows e in Exhibit letter C.)  The shared system will automatically begin counting days since letter C, G (manually triggered by the RRB SMAC) or H was triggered and will trigger release of letter D 45 -days after letter C, G or H (or the first business day after the 45th day when the 45th day is on a weekend or holiday), and will count elapsed days to begin denying paper claims from that provider effective with the 91st day after letter C, G or H was triggered.   The shared system must permit an A/B MAC (B), and DME MAC to cancel the block/field for issuance of letter C or H in the event completed in error, as long as the correction is made on the same business day as the erroneous entry.  90.5.3 - Contractor Roles in ASCA Reviews  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  A. Identification of Those Providers to be Reviewed
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A. Identification of Those Providers to be Reviewed   Separate funding will no longer be issued for these reviews annually.  Each A/B MACs (B) and DME MAC shall conduct an ASCA review annually of 20% of those providers still submitting paper bills.   The following providers will be included in the quarterly report, but contractors are not to select a  provider for review that quarter if:    A prior quarter review is underway and has not yet been completed for that provider (start date of prior review is listed in the report but not yet an enforcement decision effective date);    The provider has been reviewed within the past two years, determined to be a small provider, and there is no reason to expect the providers small status will change for at least two years (provider file past ASCA review result was SM and completion date of that review is  less than 24 months in the past); or   Fewer than 30 paper claims were submitted by the provider for the quarter.
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 Fewer than 30 paper claims were submitted by the provider for the quarter.  When calculating 20% of providers still submitting paper claims, exclude those providers mentioned above who will not be considered for an AS CA review.  For example, the A/B MAC (B) or DME MAC receives claims for 3,200 providers but only 2,000 of those submit any paper claims, and 1,800 submit more than 30 paper claims per quarter.  600 of that 1,800 have been reviewed within 2 years of the quarter in which a Medicare contractor is now determining which providers should be reviewed during that quarter and determined to be small.  75 of the paper billers in the quarterly report had reviews begin the prior quarter which are still open.  That leave s a balance of 1,125 providers who could be subject to an ASCA review during the current quarter.  1,125 is the total of the universe of providers that are candidates for review during the current quarter and the number of the universe to be reported to CMS in the A/B MACs (B) or DME MACs monthly ASCA report.  20% of 1,125 is 225 and  of 225 is 56 .  That contractor is expected to begin at least 56 new ASCA reviews during the current quarter.  By the end of the fiscal year (FY), that A/B MAC (B) or DME MA C is expected to have begun ASCA reviews of the average of the provider universe totals for the quarters multiplied by 20%.  In this example, if 1,125 providers was the average number of providers considered for ASCA review for the 4 quarters of the FY and  the contractor began ASCA reviews of 225 of those providers by the end of the FY, that A/B MAC (B) or DME MAC will have met the 20% target for that FY.   1. A/B MAC (B) and DME MAC  - Specific Selection Requirements -A/B MACs (B) and DME MACs will determine the best candidates for review from the quarterly report and will complete the block/field to identify the selected providers in the quarterly report and trigger release of Exhibit letter C to those providers.  (The A/B MACs (B) and DME MACs must furnish t he appropriate URLs for the last paragraph of the letter.)  Select candidates as follows:
(Medicare Claims Processing Manual)
a. Two -thirds from Part 1 providers beginning with those that have the largest number of paper claims and issuing letters in descending order; and   b. One third from Part 2 providers also beginning with those that have the largest number of paper claims and issuing letters in descending order.  NOTE:  In the case of a provider that submits claims under more than one PIN or NSC number, all of which are under the same TIN, and for which there are multiple entry lines in the quarterly report, the A/B MAC (B) and DME MAC shall combine the number of paper claims submitted under each of those PINs/NSCs when determining which providers to be selected for review.  For ASCA evaluation purposes, consider all of those paper claims as submitted by the same provider even though under different PINs or NSCs.  Complete the block/field for each of the providers lines in that case, but apply the same review result for each of the affected PINs/NSCs recorded for that provider.  In terms of number of reviews conducted, a review that involves multiple PINs or NSCs for the same provider is to be treated individually and multiple copies of letter C are to be issued.  If an A/B MAC (B) and DME MAC exhausts the Part 1 list and still has additional reviews to conduct in the quarter, the contractor is to increase the number of initial review letters sent to Part 2 providers.  If the Part 2 list is also exhausted for the quarter, and the contrac tor still has additional reviews to initiate, the contractor will begin to send initial review letters to those providers in Part 3 of the shared system quarterly report, again having letters issued in descending order beginning with those providers with t he largest numbers of paper claims.   A/B MACs (B) and DME MACs are to complete selection of providers to be reviewed by the end of the second month of each quarter.  B. Conducting the Reviews
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A/B MACs (B) and DME MACs are to complete selection of providers to be reviewed by the end of the second month of each quarter.  B. Conducting the Reviews   If a provider responds to letter C or D (whether triggered by a n A/B MAC or DME MAC selection of the provider for review in the quarterly report or direct issuance of the letters by an A/B MAC (A)), but does not establish eligibility to submit paper claims, the A/B MAC (A) shall notify the shared system to begin denying paper claims submitted by that provider beginning on the 91st day after release of letter C and shall issue letter E.  The A/B MAC or DME MAC shall enter ASCA review result code NE  in the shared system ASCA review result field (see 90.5.2).  This will trigger the shared system to have Exhibit letter E released by the contractors correspondence system.   If a providers response to letter C or D establishes that the provider is eligible to submit paper claims to Medicare, the A/B MAC (A) shall issue provider letter F, and the A/B MAC or DME MAC shall enter ASCA review result code SM, WA or UC (see 90.5.2 as appropriate in the ASCA review result field).  This will trigger MCS or VMS to have letter F released.   A/B MACs or DME MACs have authority to delay imposition of denial of paper claims for up to 30-days if the provider responds to letter C or D and indicates all changes needed to submit their claims electronically cannot be completed by the 90th day after letter C, but will be completed within 30 addi tional days.  An A/B MAC or DME MAC should approve an extension request of up to 30 days, if the  A/B MAC or DME MAC  has no reason to suspect the provider may not complete the changes by the specified date.
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When an extension is approved, an A/B MAC (A) mus t reset the effective date of paper claim denials as needed so FISS does not begin to deny paper claims from that provider prior to expiration of the extension period.  An A/B MAC or DME MAC must enter the new effective date (CCYYMMDD) when MCS or VMS is t o begin denying paper claims in the paper claim denial date field (see 90.5.2) and also enter NE in the ASCA review result screen/field.  MCS or VMS will begin to deny the providers paper claims on the date entered.   If based on prior experience with the  provider or knowledge of the extent of the changes the provider must make, the A/B MAC or DME MAC has reason to doubt the ability of the provider to complete the necessary changes by the 120th day, the MAC is to deny a providers extension request.  The A /B MAC (A) shall immediately notify FISS to begin denying paper claims from that provider beginning on the 91st day after issuance of letter C.  The A/B MAC or DME MAC shall enter NE in the ASCA review result screen/field; MCS or VMS shall begin to deny that providers paper claims on the 91st day after letter C was triggered.   The A/B MAC or DME MAC  does not have authority to approve more than one 30- day extension during the same review.  A/B MACs or DME MACs  must contact CMS/OIS/BAMG/Division of Transactions, Applications & Standards (DTAS) if a contractor representative thinks a providers request for an extension beyond the 120th day should be approved.  If a c  A/B MAC or DME MAC  does not endorse an extension request beyond the 120th day, the contractor should deny the request.  The A/B MAC or DME MAC shall enter NE in the ASCA review result screen/field.  If DTAS approval is requested by a contractor and DTAS does approve an extension, A/B MACs or DME MACs are to follow the requireme nts in the prior paragraph concerning resetting of the effective date for denial of that providers paper claims.
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When A/B MACs or DME MACs finish each providers ASCA review, the A/B MAC or DME MAC must enter the outcome to the provider file (see 90.5.2), except where identified as shared system responsibility, as well as enter the specific unusual circumstance when result code UC applies.   The group code CO (provider financial liability) is to be used with reason code 96 (non-covered charges), remark co de M117 (Not covered unless submitted by electronic claim), and remark code MA44 (No appeal rights).  Adjudicative decision based on law for the entire billed amount in the remittance advice sent to the provider for claims when denied as submitted on paper .  If a provider is a candidate for an ASCA enforcement review and the provider is also undergoing a fraud or abuse investigation, the A/B MAC or DME MAC has discretion to exclude that provider from the ASCA enforcement review that quarter if it could inte rfere with the fraud/abuse investigation, or alternately, may combine the ASCA review with the fraud/abuse investigation.  If an ASCA enforcement review is not conducted due to possible interference, and the provider is subsequently cleared of fraud or abuse, the ASCA enforcement review is to be conducted when that fraud/abuse investigation is completed.   Most types of ASCA exceptions/waivers apply to individual claim types only, or to submission of paper claims for temporary periods.  If a provider is sele cted for ASCA review, and the contractor determines that most of the paper claims submitted for that provider for that period:   1. Were for MSP claims when there is more than one primary payer, or for mass inoculations, or similar types of claims allowed to be submitted on paper; or   2. Were submitted on a temporary basis as result of power and communication disruption resulting from a natural disaster or similar problem outside the control of the provider; AND   3. The number of paper claims submitted for the provi der during that quarter that did not meet such criteria would not have been high enough to have resulted in selection of that provider for ASCA review in the absence of the excepted/waived claims, the contractor is to terminate that review.  THEN,
(Medicare Claims Processing Manual)
The A/B  MAC or DME MAC must enter provider ASCA review result WA (see 90.5.2) to trigger Exhibit letter F, and an A/B MAC (A) must issue letter F.   NOTE:   WA or issuance of letter F to a provider that is being waived for a reason other than the number of FTEs em ployed does not preclude the provider from A/B MAC, or DME MAC selection for review during subsequent quarters.   A/B MACs and DME MACs are not to maintain a provider FTE database, or establish a separate database of waived providers, unless an unusual sit uation waiver decision is made as result of a providers request for approval of a waiver (see 90.3.2), or as result of an ASCA review and either A/B MACs or DME MACs provider ASCA determination WA or UC (see 90.5.1) applies, or an A/B MACs (A) has issue d letter F for other than the small provider exception.  Each A/B MAC or DME MAC will maintain a local Excel spreadsheet of unusual situation waivers and requests with column headings for the name, address, legacy and NPI provider number, whether a reque sted unusual circumstance waiver was approved or denied, the effective and termination dates for an approval (if applicable), and the unusual circumstance identified in the request.   A/B MACs and DME MACs must be able to submit this spreadsheet to CMS when requested or could be asked to submit data from the spreadsheet in a report to CMS.  Provider entries in this spreadsheet shall be retained for the same period that A/B MACs and DME MACs are required to retain claims.   C. Post -Review Actions
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C. Post -Review Actions   If followi ng the start of paper claim denials, a provider subsequently submits documentation to establish that they actually had met criteria for submission of paper claims by that 91st day, the A/B MAC or DME MAC must enter SM, WA or UC as appropriate in the shared  system ASCA review result field.  This will trigger the shared system to have Exhibit letter F issued and will eliminate further paper claim denials for the provider.  An A/B MAC (A) must notify FISS to terminate denial of that providers paper claims.  T he shared system is not to reprocess any paper claims previously denied as on paper for that provider unless the provider resubmits those claims.   If a provider submits documentation to establish eligibility to submit paper claims but that eligibility is effective after the 91st day, the A/B MAC or DME MAC shall enter the date when the provider actually became eligible to submit paper claims in the appropriate field in the shared system ASCA review result screen (see 90.5.2).  There is no corresponding A/ B MAC (A) process for this, but it is considered unlikely that this situation would occur with an institutional provider.  If a provider resubmits denied claims, services furnished on or after the date of eligibility to submit paper claims may be paid but services furnished after the 90th day through the day before the provider became eligible to submit paper claims may not be paid.  They must be denied as furnished during a period for which the provider was required to bill Medicare electronically.   90.5.4 - Submission of Claims that May Always be Submitted on Paper by Providers Not Otherwise Eligible to Submit Paper Claims (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)
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If a provider determined to be ineligible to submit most types of claims on paper contacts any MAC to complain because a claim that contained services permitted to be submitted on paper (see 90.2) was denied, the MAC is to manually process and pay that claim.  These claims will only be paid at the providers re quest, assuming all other requirements are met for coverage and payment of that claim or certain services included in that claim.  Medicare systems are incapable of identifying and paying certain types of paper claims, or only certain services included in paper claims, when a provider has been determined to be otherwise ineligible for payment of all other paper claims.   90.6 - Provider Education  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Medicare contractors were required to include information on their provider Web site and in a newsletter by April 2004 to notify providers of/that:   1. Providers that do not qualify for a waiver as small and that do not meet any of the remaining exception or waiver criteria must submit their claims to Medicare electronically;   2. Small provider criteria and that small providers are encouraged to submit as many of their claims electronically as possible;   3. FTE definition and calculation methodology;   4. Exception criteria;   5. Unusual circumstance criteria;   6. Self -assessment requirements;   7. Process for submission of an unusual circumstance waiver;   8. Additional claims, such as certain claim types not supported by free billing software, that must continue to be submitted on paper pe nding any contractor or shared system modifications to enable those claims to be submitted electronically;   9. Submission of paper claims constitutes an attestation by a provider that at least one of the paper claim exception or waiver criterion applies at  the time of submission;   10. Repercussions of submitting paper claims when ineligible for submission of paper claims;  11. Post -payment monitoring to detect providers that submit unusually high numbers of paper claims for further investigation; and   12. W aiver request submitted by providers should include the providers name, address, contact person, the reason for the waiver, why the provider considers enforcement of the electronic billing requirement to be against equity and good conscience, and any othe r information the contractor deems appropriate for evaluation of the waiver request.
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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 (RRB SMAC)  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  ASCA did not differentiate among Medicare contractors or between Railroad (RR) and non-RR Medicare for applicatio n of the electronic billing requirement.  Section 90.3.1 of this chapter indicates that a provider that submits fewer than 10 claims to Medicare per month on average (fewer than 120 claims per year) is permitted to continue to submit paper claims.  As resu lt of the distribution of RR retirees though, it is not unusual for a single provider to only treat a small number of RR Medicare patients and to submit fewer than 10 claims to the RRB SMAC per month.  The same providers that treat RR Medicare patients als o treat non- RR Medicare beneficiaries however, and in most cases do submit more than 10 claims per month in total to one or more non- RR Medicare contractors.  As result, when selecting providers for an ASCA Enforcement Review, the RRB SMAC shall not exclude a provider from consideration for review simply because the quarterly ASCA report indicates the provider submitted fewer than 10 claims to the RRB SMAC.  In a departure from the rule as it applies to non- RRB SMAC Medicare contractors, submission of fewer than 10 claims per month to the RRB SMAC does not automatically qualify a provider for waiver of the electronic claims submission requirement.   Providers that submit paper claims to multiple Medicare MACs, including both RR and non-RR MACs, could have an ASCA Enforcement Review conducted by each of those contractors.  If a non- RR Medicare MAC determines that a provider does not meet any criteria which would permit that provider to continue to submit Medicare claims on paper and notifies a provider (letter E is triggered) that all paper claims submitted on or after a specific date will be denied, that same decision is to be applied to that provider if submitting paper claims to the RRB SMAC regardless of whether that provider would submit 10 or more paper cl aims to the RRB SMAC monthly.
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Provider enrollment information from non- RR MACs is sent to the RRB SMAC weekly by the MCS maintainer in a Provider Enrollment System file called SuperPES .  As a condition for submission of claims to the RRB SMAC, a provider must first enroll for submission of claims to non- RR Medicare.  The RRB SMAC uses SuperPES to determine whether any provider that sends them a claim, but that does not have a record in the RR provider enrollment system (PES), is already enrolled in non- RR Medicare.  If so, the RRB SMAC then uses the SuperPES information to establish a record for that provider in the RR PES file, or if not, rejects those claims as there is no indication t hat provider has enrolled in Medicare.  SuperPES is manually searched by RRB SMAC representatives.  It would be difficult and possibly impossible to automatically update PES due to the differences in RR and non-RR legacy provider numbers.  Addition of NPIs may not appreciably improve the ability to make one to one matches since providers can obtain more than one NPI or fewer NPIs than legacy identifiers.  Although supplemental information is submitted on claims that can often be used to match between an NPI and a single legacy identifier, there is not as  much supplemental information in the SuperPES and PES files that could be used to help make a match between the files in the absence of a claim.