evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
SuperPES includes fields (see the date and ASCA decision fields in 90.5.2) for the reporting of an ASCA review result, the date of that ASCA decision and the NPI associated with the providers non- Railroad PIN.  Multi is entered in that field if more than one NPI is associated with a PIN.  The RRB SMAC shall check SuperPES for the availability of ASCA Enforcem ent Review information when selecting providers on PES for ASCA Enforcement Reviews, as well as when first establishing a PES record for a provider.  If an ASCA review decision (NE, SM, WA or UC) is in SuperPES, that decision and the effective date of that  decision in SuperPES must be entered into that providers record in PES.  In lieu of NE however, the RRB SMAC shall enter NR in PES to indicate that the not eligible determination was made by a contractor other than the RRB SMAC.  If either SM, WA or UC applies, the effective date of the decision is the later of the date in SuperPES when that contractor began the most recent ASCA review or the date the provider became eligible to submit paper claims when that is later than the date that the denial of claims began as result of a prior NE/NR decision.  A future date may not be entered in PES for a NE/NR decision.  A future NE effective date in SuperPES signifies that the contractor has not yet completed the ASCA review and that the decision is sti ll tentative. See 90.7.1 for further use of the ASCA decision codes to determine when to issue ASCA review letters.   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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
Due to the impact of ASCA review decisions made by A/B MACs (B), it would not be reasonable to require that the RRB SMAC issue new ASCA review letters for 20 percent of the providers who send them paper bills annually without giving the RRB SMAC some credit for the additional effort expended as result of the PES -SuperPES -quarterly paper claim submit ters reports reviews the RMC is required to conduct.  It takes the RRB SMAC longer to identify providers that should be sent letters to initiate a new ASCA review and in some cases, the cross checks performed by the RRB SMAC result in disqualification of a  provider for selection for a new ASCA Enforcement Review.  To adjust for this, the RRB SMAC annual ASCA review target is to review the records of 20 percent of those providers who submit paper claims as indicated in the MCS quarterly paper claim submitter s reports, and not to necessarily initiate a new ASCA review of 20 percent of the providers that send them paper claims annually.
(Medicare Claims Processing Manual)
To compute this 20 percent, the total number of providers for whom reviews are to be conducted shall be computed as directed in 90.5.3.  To gauge the number to be reviewed during a single quarter in the same FY prior to production of the fourth quarterly report for that FY, the RRB SMAC shall multiply the total of providers who submitted paper bills in the most recent quarterly  report by 0.2 (20 percent), and then multiply again by .25.  The number of reviews to be initiated during the fourth quarter shall be computed by subtracting the total reviews identified as conducted for the first three quarters of the FY from the total n umber of reviews targeted for the FY as a whole; the difference in the totals is the number of reviews to be started during the fourth quarter.  For purposes of the monthly ASCA review report submitted to DTASdata.info prior to the fourth quarter of a FY, the total number of providers in the MCS most recent quarterly paper claim submitters report shall be entered in the eligible providers field.   The total number of providers in that quarterly report for whom ASCA review letters are actually issued to begin reviews plus those for whom a decision is made that a new review is not warranted at that time due to an ASCA review action taken by another Medicare contractor shall be entered in the Initial Review Letters Issued  for Report Period field of the monthly DTASdata .info report.  CMS realizes that an initial review letter will not actually have been issued by the RRB SMAC to each provider in this second situation, but the RRB SMAC review of ASCA data in SuperPES for those providers selected from the MCS quarterly paper claim submitters report which result in decisions not to initiate new reviews will be considered as equivalent to initiation of a new review by CMS for comparison purposes with A/B MACs (B) and to determi ne if the annual 20 percent target has been reached by the RRB SMAC .  The number of ASCA reviews completed total to be entered in the monthly report shall equal the number of ASCA reviews completed during the reporting period that were initiated with an ASCA review letter plus the number of new ASCA reviews that were determined not to be warranted that month as result of review of ASCA information in SuperPES that same month.
(Medicare Claims Processing Manual)
For the fourth quarter of the FY, the total number of providers as computed for the FY who are eligible for review, i.e., the total who submitted paper claims in each of the quarterly ASCA reports for the FY divided by four, shall be entered in the DTASdata.info monthly report as the number of Eligible Providers.  The RRB SMAC shall  follow the direction in the prior paragraph to calculate the number of Initial Review Letters Issued for Report Period and the Reviews Completed totals to be entered in those fields of the DTASdata.info reports for the months in that final quarter.  T he remaining fields of the monthly ASCA reports are to be completed by the RRB SMAC according to the existing completion instructions for that report which were previously issued to the Medicare contractors.   90.7.5 - RRB SMAC Information in ASCA Enforceme nt Review Letters  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  The letters that apply to ASCA Enforcement Reviews at the end of this chapter did not originally refer to application of decisions made by an A/B MAC (B) to a provider when billing the RRB SMAC.  These letters have now been modified to note that an ASCA Enforcement Review made by one Medicare MAC that a provider does not qualify to submit claims on paper also applies to that same provider when billing other Medic are MACs, including the RRB SMAC.  Two letters (G and H) have been added specifically for RRB SMAC use.  Letters G and H may not be sent by and do not apply to any contractor other than the RRB SMAC.  The ASCA regulation indicated that denial of claims bec ause they were not submitted to Medicare electronically would be applied on a prospective basis.  Ninety days is being allowed prior to denial in letters G and H to allow time for those providers that do not have software for submission of electronic claim s to the RRB SMAC to obtain that software from their vendor.  Addition of a RRB SMAC module to some commercial electronic claim submission software can reportedly be expensive.  As result, wording has also been included in the letters concerning the Medica re free billing software.
(Medicare Claims Processing Manual)
The cost charged by a commercial software vendor for a module to enable claims to be submitted to the RRB SMAC electronically is not a valid basis for waiver of the requirement that a provider submit their claims to the RMC electronically.  The RRB SMAC shall encourage a provider who may mention cost to use the RMCs free billing software if this would be a more cost effective method of electronic submission of their claims to the RRB SMAC.  The provider shall use either the comme rcial software of their choice or the Medicare free billing software and shall begin to submit their claims to the RRB SMAC electronically if they wish to continue to be paid for services furnished to RR Medicare beneficiaries.   The ASCA Enforcement Review  letters now refer to an ASCA electronic claim submission requirement made by one MAC as applying to all MACs because that is actually how ASCA decisions are to be applied.  CMS has not enforced this across the board due to the lack of a vehicle for sharin g decisions across contractor lines, other than in the case of the RRB SMAC.  If a vehicle becomes available to do this in the future for contractors other than the RRB SMAC, CMS will begin to require that this be done.  Sharing of these decisions across t he board would require coordination to eliminate the possibility that more than one contractor could conduct reviews of the same provider at the same time so this issue would also need to be addressed in any subsequent change request issued for this purpos e.  90.7.6 - RRB SMAC Costs Related to Use of ASCA Review Information in SuperPES Files  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Costs for FY 2009 and later for ASCA review expenses as delineated are to be included in the annual operations budget request submitted by the RRB SMAC.   Exhibits of Form Letters  (Rev. 2965, Issued: 05- 23-14, Effective: 07- 25-14, Implementation: 07- 25-14)  Exhibit A - Response to a non - unusual circumstance waiver request  (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
(Medicare Claims Processing Manual)
Date:   From:  MAC (Name and address may appear on masthead)   To:  Organizational Name of Provider and Mailing Address   Subject:  Electronic Claim Submission Waiver Request  You recently submitted a re quest for waiver of the Administrative Simplification and Compliance Act (ASCA) requirement that claims be submitted electronically to be considered for Medicare payment.  Providers are to self -assess to determine if they meet the criteria to qualify for a  waiver.  A request for waiver is to be submitted to a Medicare contractor only when an unusual circumstance, as indicated in b, c or d below applies.  Medicare will not issue a written waiver determination unless b, c or d applies.   ASCA prohibits payment of service and supply claims submitted to Medicare on paper, except in limited situations that apply either 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 p roviders -To qualify, a provider required to use a CMS -1450 form 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 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 cla ims;  5. Claims sent to Medicare when more than 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 Administrative Contractors (MACs) 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;