CMS Pub. 100-04, ch. 24, § 50.5.1

Clearinghouse, Billing Service, or Vendor Software

(Rev. 2803, Issued: 10-28-13, Effective: 09-17-13, Implementation: 09-17-13)

Many claim submitters use the same vendor’s software product, or the same

clearinghouse to submit their electronic claims to Medicare. In those cases, A/B MACs

and CEDI are not required to test each submitter that uses the same software, or each

provider or billing agent that uses the same clearinghouse. A/B MACs and CEDI may

require potential third party submitters to have an approved Medicare provider as a client

prior to testing with such third parties. It is sufficient to test with a small number of users

of the same software to establish that the software is compliant, or to simply test with a

single provider using a clearinghouse to establish the compliancy of the clearinghouse’s

software and connectivity for transmission of claims data. Likewise, once A/B MACs

and CEDI have tested the validity of the free/at cost billing software they distribute on

request, the A/B MACs and CEDI are not expected to test providers that have elected to

use that billing software.

Providers who submit transactions directly to more than one A/B MAC and/or CEDI, and

billing services and clearinghouses that submit transactions to more than one A/B MAC

and/or CEDI, must contact each A/B MAC and/or CEDI with whom they exchange EDI

transactions to inquire about the need for supplemental testing whenever they plan to

begin to use an additional EDI transaction, different or significantly modified software

for submission of a previously used EDI transaction, or before a billing agent or

clearinghouse begins to submit transactions on behalf of an additional provider. A/B

MAC and/or CEDI may need to retest at that time to re-establish compatibility and

accuracy, particularly if there will also be a change in the telecommunication connection

to be used.

Billing services and clearinghouses are not permitted to begin to submit or receive EDI

transactions on behalf of a provider prior to submission of written authorization by the

provider that the billing agent or clearinghouse has been authorized to handle those

transactions on the provider’s behalf. See Section 30 of this Chapter for further

information on EDI Enrollment.