Returning Paper Claims Received From Clearinghouses

MLN Matters articles are subject to revision. We recommend that you visit http://www.cms.hhs.gov/MLNMattersArticles/ frequently to stay abreast of updates. This MLN Matters article relates to Change Request 5341. This is also available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5341.pdf.

Clearinghouses Must Submit Claims Electronically

Provider Impact
If a clearinghouse submits claims for you on paper (rather than electronically), your payments may be affected. The Administrative Simplification Compliance Act (ASCA) requires that claims a clearinghouse submits to Medicare on your behalf must be submitted electronically. When your carrier or fiscal intermediary (FI) identifies that a clearinghouse has submitted a claim for you on paper, they will return the claim unprocessed to the clearinghouse.

Background
Section 3 of the Administrative Simplification Compliance Act ( ASCA), PL 107-105; the implementing regulation at 42 CFR 424; and the Medicare Claims Processing Manual Chapter 24, Section 90-90.6 and its exhibits all require (except in limited situations) that you submit claims to Medicare electronically. And, while ASCA regulations do allow you (as a provider) to submit some, or all, claims on paper in very specific and limited instances; HIPAA covered entities (other than providers) are not eligible for an exemption from these electronic Medicare claim submission requirements.

CR 5341, from which this article is taken, addresses claims that your clearinghouse submits to Medicare on your behalf. To be specific, if you contract with a clearinghouse to send claims to Medicare for you, they are required to submit these claims electronically.

There is evidence that some clearinghouses are routinely submitting paper claims without the providers' knowledge. You should be aware that your carriers and FIs, having identified that a provider's clearinghouse has submitted your claims in paper form, will return them to the clearinghouse without action.

Additional Information
The official instruction (CR 5341) issued to your Medicare contractor (carriers, durable medical equipment regional carrier (DMERC), DME Medicare Administrative Contractor (DME MAC), fiscal intermediary (FI), or Part A/B Medicare Administrative Contractor (A/B MAC)) regarding paper claims that they receive from clearinghouses is located on CMS' Web site at http://www.cms.hhs.gov/Transmittals/downloads/R247OTN.pdf.

If you have questions, please contact our office at 1-866-801-5301.

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