CMS Pub. 100-04, ch. 24, § 50.1.2

An EDI transaction is defined by its initial manner of receipt. Depending upon the

capability of the A/B MAC, DME MAC and CEDI and the details negotiated with

electronic claim submitters, an electronic claim could be submitted via central processing

unit (CPU) to CPU transmission, dial up frame relay, direct wire (T-1 line or similar), or

personal computer modem upload or download (also see Section 50.1.3).

When counting electronic claims for workload reporting, the A/B MAC, DME MAC and

CEDI include data on all bills received for initial processing from providers directly or

indirectly through another A/B MAC (A), etc. They also include data on demand bills

and no-pay bills submitted by providers with no charges and/or covered days/visits. See

§ 90 of this chapter for information about application of the claims payment floor when a

claim is submitted electronically in a non-HIPAA-compliant format.

A/B MACs and DME MACs are not permitted to classify the following as electronic

claims for Electronic Data Interchange (EDI) reporting, for payment floor or

Administrative Simplification Compliance Act (ASCA, see section 90) mandatory

electronic claim submission purposes:

• Bills received from providers if they are incomplete, incorrect, or inconsistent,

and consequently returned for clarification. Individual controls are not required

for these bills;

• Adjustment bills (A/B MAC (A) only);

• Home Health Agency (HHA) bills where no utilization is chargeable and no

payment has been made, but which have been requested only to facilitate record

keeping processes (There is no CMS requirement for HHAs to submit no payment

non-utilization chargeable bills.);

• Bills paid by an HMO and processed by the contractor; and

A/B MACs, DME MACs and CEDI are not permitted to accept claims via fax-imaging,

tape/diskette or similar storage media. A/B MACs, DME MACs and CEDI are to assist

billers using such media to transition to more efficient electronic media.