evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
2. Claims for paym ent under a Medicare demonstration project that specifies paper submission-By their nature, demonstration projects test something not previously done, such as coverage of a new service.  As a result of the novelty, the code set that applies to the new service may not have been included as an accepted code set in the claim implementation guide(s) adopted as HIPAA standards.  The HIPAA regulation itself makes provisions for demonstrations to occur that could involve use of alternate standards.  In the event a Medicare demonstration project begins that requires some type of data not supported by the existing claim formats adopted under HIPAA, Medicare could mandate that the claims for that demonstration be submitted on paper.  In the event demonstration data can be supported by an adopted HIPAA format, Medicare will not require use of paper claims for a demonstration project. Demonstrations typically involve a limited number of providers and limited geographic areas.   Providers that submit both demonstration and regular claims to Medicare may be directed to submit demonstration claims on paper.  Non- demonstration claims must continue to be submitted electronically, unless another exception or waiver condition applies to the provider.  3. Obligated to Accept as Payment in Full (OTAF) Medicare Secondary Payer (MSP) Claims when There is More than One Primary Payer - An OTAF adjustment (also see the Medicare Secondary Payment Manual) is made when a provider, physician or supplier agrees as result of negotiation or otherwise to receive a payment rate that is higher or lower than a payers normal allowed amount as payment in full for particular services or supplies.  By regulation, if a primary payers OTAF amount is lower than the charge for the related service that appears on the claim, Medicare must include the OTAF adjustment when calculating the amount of Medicares secondary payment.
(Medicare Claims Processing Manual)
The OTAF is identified in the CAS Segment with the Group Code of CO. The CO is used both on the ASC X12 835 remittance and the ASC X12 837 claim.  4. MSP Claims When There is More than One Primary Payer and More Than One Allowed Amount-In an MSP situation, Medicare needs to use a primary payers allowed and paid amounts to calculate the supplemental amount that can be paid by Medicare.  In some cases, a beneficiary is covered by more than one other primary payer.  Each of those other payers must complete adjudication before Medicare can process those claims.  The ASC X12 837 current HIPAA version IGs permit reporting of payment information from more than one other payer, but not for reporting of separate allowed amounts at the line or claim level for more than one payer.  As result of this limitation, when there is more than one primary payer, and the allowed amounts differ, a provide r is permitted to submit the claim to Medicare on paper, with the RA/EOB from each of the primary payers attached.   Except for OTAF claims when there is also more than one primary payer, or if a provider is small or meets one of the temporary exception cri teria, such as disruption of electricity or communications, no other types of MSP claims, such as MSP claims when there is only one primary payer, may be submitted to Medicare on paper. Claims submitted by Medicare beneficiaries.   90.3 - Unusual Circumstance Waivers  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Congress granted the Secretary considerable discretion to decide what other circumstances should qualify as unusual circumstances for which a partial (applies to certain claim types or for a defined period of time) or full waiver of the electronic claim submission requirement would be appropriate.  The Secretary delegated that authority to CMS.  In the event it is determined that enforcement of the electronic claim submission requirement would be against equity and good conscience as result of an unusual circumstance, CMS will waive the electronic claim submission requirement for temporary or extended periods.  In those situations, providers ar e encouraged to file claims electronically where possible, but electronic filing is not required.
(Medicare Claims Processing Manual)
CMS has in turn delegated certain authority to the A/B MACs or DME MACs to determine whether an unusual circumstance applies.  Providers who feel they should qualify for a waiver as result of an unusual circumstance must submit their waiver requests to the A/B MACs or DME MACs to whom they submit their claims.  The A/B MACs or DME MACs must issue a form letter (Exhibit A) in the event of receipt of a written waiver request that does not allege an unusual circumstance.   As required by the Privacy Act of 1974, letters issued to a provider to announce a waiver decision must be addressed to the organizational name of a provider and not to an individual (eithe r a sole practitioner, employee or the owner of the provider organization).  The organizational name is generally a corporate name under which the provider is registered as a Medicare provider or the name used to obtain an EIN from the IRS.  In some cases,  an unusual circumstance or the applicability of one of the other exception criteria may be temporary; in which case, the related waiver would also be temporary.  Once the criteria no longer apply, that provider is again subject to the Medicare electroni c claim submission requirement. Likewise, some exception and waiver criteria apply to only a specific type of claim, such as an OTAF secondary claim when there is more than one primary payer for only the current HIPAA version.  Other claim types not covere d by an exception or waiver must still be submitted to Medicare electronically, unless the provider is small or meets other exception or unusual circumstance criteria.   90.3.1 - Unusual Circumstance Waivers Subject to Provider Self -Assessment  (Rev. 2803, I ssued: 10 -28-13, Effective: 09-17-13, Implementation: 09-17-13)
(Medicare Claims Processing Manual)
90.3.1 - Unusual Circumstance Waivers Subject to Provider Self -Assessment  (Rev. 2803, I ssued: 10 -28-13, Effective: 09-17-13, Implementation: 09-17-13)  The following circumstances always meet the criteria for waiver.  Providers that experience one of the following unusual circumstances are automatically waived from the electronic claim sub mission requirement for either the indicated claim type or the period when an unusual situation exists. A provider is to self- assess when one of these circumstances applies, rather than apply for contractor or CMS waiver approval. A provider may submit claims to Medicare on paper or via other non- electronic means when one of these circumstances applies.  A provider is not expected to pre- notify their A/B MACs or DME MACs that one of the circumstances applies as a condition of submission of non- electronic claims.    Dental claims -Medicare does not provide dental benefits.  Medicare does cover certain injuries of the mouth that may be treated by dentists, but those injury treatments are covered as medical benefits.  Less than .01 percent of Medicare expenditures were for oral and maxillofacial surgery costs in 2002. The ASC X12 837 professional claim TR3 standard for submission of medical claims requires submission of certain data not traditionally reported in a dental claim but which is needed by payers to adjudicate medical claims.  As result, Medicare contractors have not implemented the dental claim standard adopted for national use under HIPAA.  Due to the small number of claims they would ever send to Medicare, most dentists have not found it cost effective to invest in software they could use to submit medical claims to Medicare electronically.  For these reasons, dentists will not be required to submit claims to Medicare electronically.    Disruption in Electricity or Phone/Communication Services --In the event of a major storm or other disaster outside of a providers control, a provider could lose the ability to use personal computers, or transmit data electronically.  If such a disruption is expected to last more than 2 business days, all of the affected providers are automatically waived from the electronic submission requirement for the duration of the disruption.  If duration is expected to be 2 business days or less, providers should simply hold claims for submission when power and/or communication are restored.
(Medicare Claims Processing Manual)
 A provider is not small based on FTEs, but submits fewer than 10 claims to Medicare per month on average (not more than 120 claims per year).  This would generally apply to a provider that rarely deals with Medicare beneficiaries.   4. Non-Medicare Managed Care Organizations  that are able to bill Medicare for copayments may continue to submit those claims on paper.  These claims are not process able by the MSPPay module and must be manually adjudicated by Medicare contractors.      90.3.2 - Unusual Circumstance Waivers Subject to a Contractor Evaluation for CMS Decision  (Rev.4096, Issued: 08- 03-18, Effective: 11-05-18, Implementation: 11-05-18)  A provider may submit a waiver request to their A/B or Durable Medical Equipment  Medicare Admin istrative Contractors (A/B or DME MACs) claiming other types of unusual circumstances  outside of  their control  prevent submission of  electronic claims. It is the responsibility of the provider to submit appropriate documentation including request application with Provider name, address, email, and phone number to establish the validity of  a waiver request in this situation . Requests received without documentation and as above stated information to fully explain and justify why enforcement of the requirement would be against equity  and good conscience  in these cases will be  denied. If the A/B MAC or, DME MAC agrees that the waiver request has merit, the request must be forwarded Centers for Medicare and Medicaid Services, Office of Information Technology, Applications Management Group, to the Division of Transactions, Applications & Standards (CMS/OIT/AMG/DTAS) Email box (ASCAwaiverRequest@cms.hhs.gov) for Review and issuance of the CMS decision. The contractor must forward an explanation letter as to why the contractor (MAC)  recommends CMS approval to DTAS with the waiver request. The contractor will be copied on the decision notice DTAS issues to the requestor.
(Medicare Claims Processing Manual)
If the contractor does not consider an unusual circumstance to be met, and does not recommend DTAS approval, the contractor must issue a form letter (Exhibit B). As required by the Privacy Act of 1974, letters issued to a provider to announce a waiver decision must be addressed to the organizational name of a provider and not to an individual (whether a sole practitioner, employee, or an owner of the provider organization). The organizational name is generally a corporate name under which the provider is registered as a Medicare provider or that is used to obtain an EIN.  Unusual Circumstances that Require CMS Review:   1. Provider alleges that the claim transaction implementation guides adopted under HIPAA do not support electronic submission of all data required for claim adjudication. (If a waiver is approved in this case, it will apply  only to the specific claim type (s) affected by the IG  deficiency.)   NOTE: A Medicare contractor is not permitted to prohibit submission of an electronic claim because there is a paper attachment. The ASC X12 8 37 claim Technical Review 3 (TR3) contains information   for provider use of the PWK segment to alert a Medicare contractor that attachment information is being  separately  submitted. Some Medicare contractors had issued instructions regarding  use of the ASC X12 837- claim NTE segment to report attachment information in lieu of PWK. Submitters of claims for which there  are attachments essential for adjudication must comply with  the ASC X12 attachment  reporting direction issued  by their Medicare contractor f or the immediate  future. System changes will be made for contractor use of PWK in conjunction with implementation of the attachment standard, which  is scheduled for future adoption as  a HIPAA standard. NCPDP claims should not  have attachments.   MACs are required to accept claims electronically for  reassociation with attachments submitted separately on paper or via other means such as fax when supported by individua l contractors. MACs  must include the process for submission of claims when there are attachm ents in a newsletter article and on their Web site with other applicable information concerning the ASCA requirement that Medicare claims be submitted  electronically.
(Medicare Claims Processing Manual)
2. A provider is not small, but all those employed by the provider have documented disabilities that would prevent their use of a personal computer for electronic submission of claims. In this case, the documentation  that establishes  the disability of those  staff members would  need to be issued  by providers  other than the provider  requesting  the waiver and would  need to be submitted  for review.   3. Any other unusual situation that is documented by a provider to establish that enforcement of the electronic claim submission  requirement  would  be against equity and good consci ence. The provider  must submit a  waiver request with appropriate documentation  to their A/B MAC or DME MAC for evaluation by that contractor, and if approved at that level, for subsequent review by CMS.  In the event other situations  are identified  and approved by CMS for which a requirement  for electronic  filing  would  always be considered  against equity  and good conscience, those situations  will  be added  to the self-assessment  list.  90.4 - Electronic and Paper Claims Implications of Mandatory Electronic Submission  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Claims providers submit via a DDE screen maintained by a Medicare shared system or transmitted to an A/B MAC or DME MAC using the free/low cost claims software issued by Medicare are considered electronic.  When enforcing the electronic claim submission requirement, CMS will take into account those limited situations where a provider submitted paper claims because the free billing software they were issued may have been temporarily unable to accommodate submission of a secondary or other particular type of claim.   A/B MACs and DME MACs are prohibited from requiring submission of paper claims in any situations on or after October 16, 2003, except as specifically permitted by CMS.  A/B MACs and DME MACs are to assume for processing purposes that claims submitt ed by a provider on paper October 16, 2003, and later are submitted by providers that are small or that do meet exception criteria, barring information received from other sources to the contrary.  Submission of a paper claim October 16, 2003, or later wil l be considered an attestation by a provider that waiver criteria are met at the time of submission.   90.5 - Enforcement  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)
(Medicare Claims Processing Manual)
90.5 - Enforcement  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  See 90.7- 90.7.6 for additional requirements specific to the Railroad Retirement Board Specialty MAC (SMAC).   90.5.1 - FISS Role in ASCA Enforcement  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Enforcement will be conducted on a post -payment basis during those periods when directed by CMS.  FISS will prepare quarterly reports for the A/B MACs (A) and (HHH)  for those periods as directed by CMS that list each providers name, provider number, addre ss, number of paper claims received under each provider number, percentage of paper claims to total claims for each provider, and the period being reported, e.g., claims processed July 1, 2005 -  September 30, 2005.  The data in the reports must be arrayed in descending order with those providers receiving the highest number of paper claims at the beginning of the report.  These reports must be available by the end of the month following completion of a calendar quarter, e.g., on October 31 for July 1 -Septem ber 30.   90.5.2 - MCS & VMS Roles in ASCA Enforcement  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)
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90.5.2 - MCS & VMS Roles in ASCA Enforcement  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  As result of the substantially higher number of paper claims sent to DME MACs and A/B MACs (B) than to A/B MACs (A) or (HHH) , somewhat different ASCA quarterly report requirements are being applied for the A/B MACs (B) and DME MACs quarterly reports.  MCS and VMS will prepare an online (printable at the contractors discretion) report each calendar quarter (October -December, January -March, April -June and July -September) for each A/B MAC (B) and DME MAC as applicable.  Each report must identify the months and year for which the data is being reported.  The report must be available for contractor use by the end of the month that f ollows completion of a calendar quarter, e.g., by October 31 for July 1 -September 30.  The following fields are in the provider file to assist with preparation of these reports, A/B MACs (B) and DME MACs tracking of report history, and selection of provide rs for ASCA Enforcement Reviews:   1. Date (CCYYMMDD) most recent ASCA enforcement review began (shared system will populate with the trigger date of the most recent initial review letter, Exhibit letter C or H; see 90.7 for information on RRB SMAC population of this field for letter G);   2. Date (CCYYMMDD) denial of paper claims began or is to begin as provider not eligible to submit paper claims  (shared system shall populate with the 91st day after letter C, G or H is triggered and an ASCA result has not been entered , or a contractor shall reset that date to the date after an approved extension period expires; see 90.5.3.B);  3. Effective date (CCYYMMDD) of provider eligibility to submit paper claims if effective after the date the provider was initially determi ned to be not eligible to submit paper claims (see 90.5.3.C; contractor must populate using a shared system field established for reporting of this date);
(Medicare Claims Processing Manual)
4. Result of the most recently completed ASCA enforcement review.  The ASCA review result field is use d for contractor entry of a 2- character code to identify the result of an ASCA review.  NE-Provider not eligible to submit paper claims (shared system will populate when paper claim denials begin; see 90.7 for exception when this will be populated by the RRB SMAC);   5. When one of the following applies, the later of 1) the date the most recent ASCA enforcement review began or 2) the date this decision was effective if after the date a provider was initially determined not to be eligible to submit paper claims  will be considered the effective date of the decision:   SM--Provider determined to be small based on providers FTEs (contractors shall populate);  WA--Provider determined to meet another ASCA exception or waiver condition, including submission of fewer than 10 claims a month on average to Medicare (does not include a  90.3.3, chapter 24 unusual circumstance; see 90.7.1 for RRB SMAC application of the fewer than 10 claims per month waiver; contractors shall populate); or  UC--Provider determined eligible for an unusual circumstance waiver per 90.3.3 of chapter 24 (contractors shall populate).  When UC applies, a 60-byte field must be supplied by the shared system for contractor entry of the specific unusual circumstance.  The shared system m ust rejec t a UC entry unless an entry of at least 6 alphanumeric characters is entered in the 60- byte unusual circumstance field.   A. Quarterly MCS and VMS Provider Online ASCA Report
(Medicare Claims Processing Manual)
A. Quarterly MCS and VMS Provider Online ASCA Report   The quarterly ASCA report prepared by MCS or VMS must be in four parts:  Part 1 -This Part must contain information on those providers that submitted some claims electronically and others on paper that quarter.  Part 1 must indicate the: name; taxpayer identification number (TIN); legacy provider identifier (PIN or NSC number used for payment); the number of paper claims submitted that quarter under that identifier); the number of electronic claims submitted that quarter under that PIN or NSC number; the percentage of those claims that were on paper; date the providers most recent ASC A enforcement review began; effective date of the providers most recent ASCA enforcement review decision; and the result code from that most recent review.  The report sent to the RMC must include the ZIP Code of the provider, extended if available.  This part must be organized in descending order according to the number of paper claims submitted for each provider that quarter.  If a provider has more than one PIN or NSC number, but claims under all of those identifiers are covered by the same TIN, the lis ting for the all PINs or NSC numbers issued that provider are to be reported in successive entries in Part 1.  MCS and VMS shall report the first entry for that provider in accordance with the descending order rule based on either the total number of paper claims submitted under all of the PINs or NSC numbers or the number of paper claims submitted under the PIN or NSC number with the highest number of paper claims, followed immediately by the separate entries for each of the other PINs/NSC numbers associat ed with that same TIN.  The listings for the other PINs/NSC numbers associated with that TIN are also to be in descending order according to the number of paper claims submitted under each identifier.
(Medicare Claims Processing Manual)
Part 2 -This Part must contain information on those providers that submit all of their claims on paper and submitted 100 or more claims that quarter.  Part 2 must indicate the name; TIN; legacy provider identifier (PIN or NSC number); the number of paper claims submitted for each listed provider that quarter under that identifier; date the providers most recent ASCA enforcement review began; effective date of the providers most recent ASCA enforcement review decision; if for the RMC, the ZIP Code (extended if available); and ASCA review result code from that most recent review.  This part must be organized in descending order according to the number of paper claims submitted for each provider that quarter.   In the case of a provider that has more than one PIN or NSC number used to bill that quarter which are covered by the same TIN, apply the reporting directions located at the end of Part 1.   Part 3 -This Part must contain information on those providers that submitted only paper claims and who submitted fewer than 100 paper claims during that quarter.  Part 3 must indicate the name; TIN; legacy provider identifier (PIN or NSC number); the number of claims submitted for each listed provider that quarter; date the providers most recent ASCA enforcement review began; effective date of the providers most recent A SCA enforcement review decision; if for the RMC, the ZIP Code (extended if available); and ASCA review result code from that most recent review.  This part must be organized in descending order according to the number of paper claims submitted for each provider during that quarter.   In the case of a provider that has more than one PIN or NSC number used to bill that quarter which are covered by the same TIN, apply the reporting directions located at the end of Part 1.   Part 4 -The total number of providers f or which one or more paper claims were submitted during the quarter.  The number in Part 4 is intended to represent the unduplicated total of all providers that could potentially be considered for ASCA Enforcement Review selection.