The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except in limited situations. All initial claims for reimbursement from Medicare must be submitted electronically as of October 16, 2003, with limited exceptions. Initial claims are those claims submitted to Medicare Fee-for-Service carrier, DME Medicare Administrative Contractor, or fiscal intermediary for the first time, including resubmitted previously rejected claims, claims with paper attachments, demand bills, claims where Medicare is secondary and there is only one primary payer, and non-payment claims. Initial claims do not include adjustments submitted to intermediaries on previously submitted claims or appeal requests. This requirement does not apply to those claims submitted by beneficiaries or by providers that only furnish services outside of the United States, to Medicare managed care plans, or to health plans other than Medicare.
All providers are required to submit claims electronically unless they meet one of the following exceptions:
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Exceptions
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Unusual Circumstances
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- Claims submitted by a 'small provider' (fewer than 10 full time employees for Part B)
- Roster billing of vaccinations
- Claims submitted to Medicare Demonstration Project
- MSP claims with more than one primary payer
- Claims submitted by Medicare Beneficiaries
- Dental claims
- Services furnished outside the United States
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- Disruption in electricity or phone/communication service for more than two business days
- Provider submits fewer than 120 claims to Medicare per year
- Non-Medicare Managed Care Organization claims billed for copayments
- Employees have documented disabilities that prevent using computers
- Other unusual situation documenting that enforcement would be 'against equity and good conscience'
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Palmetto GBA monitors compliance with the requirement to submit electronic claims on a 'post-payment' basis:
- Palmetto GBA will analyze reports displaying the number of paper claims that all providers submitted each quarter
- By the end of the month following the quarter, selected providers who have submitted the highest numbers of paper claims will be reviewed
- Palmetto GBA will ask these providers to provide information that establishes the exception criteria listed above
Palmetto GBA strongly encourages all providers to submit claims electronically if possible. By law, electronic claims can be paid more quickly than paper claims. Electronic Medicare claims can be paid as soon as 14 days after they are received, while paper claims cannot be paid until at least 28 days after receipt. In addition, processing paper claims has increased administrative, postage and handling costs.
Details on each of these exceptions and instructions are available on the Palmetto GBA Web site.