Paper Claims Submission and Enforcement Clarified
WPS has received inquiries regarding the requirement to file claims electronically to Medicare. The Administrative Simplification Compliance Act (ASCA) was signed into law on December 27, 2001. ASCA granted an extension from the original HIPAA Transactions and Code Sets compliance date, October 16, 2002. ASCA also required mandatory electronic submission of Medicare claims as of October 16, 2003 (not July 2005). The requirement to file Medicare claims electronically is not affected by deployment of contingency.
ASCA provides that no payment may be made by Medicare for items or services for which a claim was received in a non-electronic format, e.g. paper; claims must be submitted electronically to Medicare. What did go into effect in July 2005 is that Medicare will monitor paper claims submissions on a quarterly basis. If monitored, providers must establish they are eligible to submit paper claims. If the provider is found in violation, subsequent paper claims will be denied. Providers in violation may be subject to claim denials, overpayment recoveries and interest. Medicare published information regarding the ASCA monitoring in the March 2005 Communiqué. Additional information regarding the enforcement of paper claims is available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3440.pdf (pdf - 3 pages; 332KB).
ASCA does provide some limited exceptions to the mandatory submission of Medicare claims. Exceptions include: small providers (e.g. a physician, practitioner, facility, or supplier with 9 or fewer full-time equivalent employees); roster billing of mass immunizations covered by Medicare; claims for payment under Medicare demonstration projects when information is required that cannot be submitted electronically; claims where Medicare is the tertiary payer to two (or more) primary payers; e.g. Medicare is the third payer (not to be confused with claims where Medicare is the secondary payer); and dental claims to Medicare. Additionally, CMS made provisions for a "Request for Waiver".
Some of the most common paper claims submissions include Medicare Secondary Payer (MSP) claims, which require additional information and resubmissions, all of which can be filed electronically. MSP claims can be filed electronically, as long as all the necessary information is provided in the proper electronic data elements (January 2003 Communiqué). Claims which require additional documentation also can be filed electronically if indicating "Documentation Available Upon Request" (October 2003 Communiqué).
If your office sends certain claim types on paper you should determine why, and if the claim type meets one of the ASCA limited exceptions. If it does not, verify with your vendor that the necessary data elements are present to support electronic billing of the claim type and document your compliance efforts. Medicare does offer free billing software, which may aid in your ASCA compliance efforts for problematic claim types and allow you to fully meet the requirements of ASCA.
If you need additional information you may also contact the WPS EDI Hotline for IL, MI & WI: 877-567-7261, or for MN: 952-885-2811, 952-885-2881 or 952-885-2882.
