CMS Pub. 100-04, ch. 24, § 40.2.4.5

A/B MACs, and CEDI will provide free/at cost software for their providers to use on a

Windows-based PC for electronic submission of HIPAA-compliant claims to Medicare.

At a minimum, this basic software must contain the following:

• Edits to prevent incomplete and inaccurate claims from entering the system;

• “User friendly” qualities including:

o A low initial investment, as well as low-cost upgrades, on the part of the

submitter;

o Minimal effort for both the software installation and training for the submitter;

and

o Clear and understandable software documentation, including information

about where to receive additional help.

This software must also be able to identify when Medicare is a secondary payer and to

collect data elements concerning a primary payer’s payment, standard claim adjustment

reason codes and adjustment amounts made by a primary payer prior to submission of a

claim to Medicare for secondary payment.

A/B MACs and CEDI are not funded to issue free/at cost software for other than

submissions of ASC X12 837 claim inbound transaction. NCPDP has indicated software

for billing NCPDP formatted claims was already in widespread use by retail pharmacies

and there was not a need for Medicare to fund development of free billing software for

retail pharmacies.

The software is free/at cost but A/B MACs and CEDI may charge a fee up to $25.00 per

request to recoup their postage, reproduction, and handling expenses when a provider

requests the software be sent via diskette, CD, or other medium, rather than downloaded

by a provider from the Medicare contractor’s web page (if not precluded by a software

copyright or licensing agreement). A/B MACs and CEDI are to complete upgrades to

their free/at cost billing software to correspond to the requirements of the current X12

version of the transactions. Prior to distributing the initial or updated versions, A/B

MACs and CEDI will scan the free/at cost billing software with a current anti-virus

program. Whenever A/B MACs and CEDI issue a new version of their free/at cost

billing software, they shall notify providers to terminate use of the earlier version of the

Medicare free/at cost billing software within 90-days of release of the updated software.

NOTE: The free-billing software distributed by A/B MACs (A) is maintained by the

shared system maintainer. A/B MACs (A) are responsible for testing and distribution of

that software only. There is not a similar common source of free billing software or

maintenance for the A/B MACs (A) or A/B MACs (B). A/B MACS or A/B MACs (B)

are encouraged to obtain and license for distribution Medicare Part B billing software.

This software is available to A/B MACS and A/B MACs (B) for purchase and licensing

from software companies.