CMS Pub. 100-04, ch. 24, § 90.2

It has been determined that due to limitations in the claims transaction formats adopted

for national use under HIPAA, it would not be possible in some cases to submit certain

claims to Medicare electronically. Providers are to self-assess to determine if they meet

these exceptions. At the present time, only the following claim types are considered to

meet this condition for self-assessment purposes:

1. Roster billing of inoculations covered by Medicare-Although flu shots and similar

covered vaccines and their administration can be billed to Medicare electronically,

one claim for one beneficiary at a time, some suppliers have been permitted to

submit a single claim on paper with the basic provider and service data and to

attach a list of the Medicare beneficiaries to whom the vaccine was administered

and related identification information for those beneficiaries. This is referred to as

roster billing. The claim IGs adopted under HIPAA provide for submission of

single claims to a payer for single individuals, but cannot be used to submit a

roster bill for multiple individuals.

Flu and pneumonia inoculations are often administered in senior citizen centers,

grocery stores, malls, and other locations in the field. It is not always reasonable

or hygienic to use a laptop computer to register all necessary data to enable a

HIPAA-compliant claim to be submitted electronically in such field situations,

particularly when a single individual is responsible for collection of the data and

administration of the inoculations. Due to the low cost of these vaccinations, it is

not always cost effective to obtain all of the data normally needed for preparation

of a HIPAA-compliant claim. Such suppliers rarely have a long-term health care

relationship with their patients and do not have a need for the extensive medical

and personal history routinely collected in most other health care situations.

It is in the interest of Medicare and public health to make it as simple as possible

for mass inoculation activities to continue. Although suppliers are encouraged to

submit these claims to Medicare electronically, one claim for one beneficiary at a

time, this is not required except in the case of multi-state companies that signed an

agreement with a single Medicare contractor for submission of all flu shots to that

single contractor for those states, and who agreed to submit those claims

electronically as a condition for centralized billing of those inoculations. In the

absence of an electronic format that would allow a single claim for the same

service to be submitted on behalf of multiple patients using abbreviated data,

suppliers currently allowed to submit paper roster bills may continue to submit

paper roster bills for inoculations.

This inoculation waiver applies only to injections such as flu shots frequently

furnished in non-traditional medical situations, and does not apply to injections

including flu shots when furnished in a traditional medical setting such as a

doctor’s office or an outpatient clinic as a component of other medical care or an

examination. In traditional medical situations where the provider is required to bill

the other services furnished to the patient electronically, a flu shot or other

inoculation is also to be included in the electronic claim sent to Medicare for the

patient.

2. Claims for payment under a Medicare demonstration project that specifies paper

submission-By their nature, demonstration projects test something not previously

done, such as coverage of a new service. As a result of the novelty, the code set

that applies to the new service may not have been included as an accepted code set

in the claim implementation guide(s) adopted as HIPAA standards. The HIPAA

regulation itself makes provisions for demonstrations to occur that could involve

use of alternate standards. In the event a Medicare demonstration project begins

that requires some type of data not supported by the existing claim formats adopted

under HIPAA, Medicare could mandate that the claims for that demonstration be

submitted on paper. In the event demonstration data can be supported by an

adopted HIPAA format, Medicare will not require use of paper claims for a

demonstration project. Demonstrations typically involve a limited number of

providers and limited geographic areas. Providers that submit both demonstration

and regular claims to Medicare may be directed to submit demonstration claims on

paper. Non-demonstration claims must continue to be submitted electronically,

unless another exception or waiver condition applies to the provider.

3. “Obligated to Accept as Payment in Full” (OTAF) Medicare Secondary Payer

(MSP) Claims when There is More than One Primary Payer- An OTAF adjustment

(also see the Medicare Secondary Payment Manual) is made when a provider,

physician or supplier agrees as result of negotiation or otherwise to receive a

payment rate that is higher or lower than a payer’s normal allowed amount as

payment in full for particular services or supplies. By regulation, if a primary

payer’s OTAF amount is lower than the charge for the related service that appears

on the claim, Medicare must include the OTAF adjustment when calculating the

amount of Medicare’s secondary payment.

The OTAF is identified in the CAS Segment with the Group Code of “CO”. The

CO is used both on the ASC X12 835 remittance and the ASC X12 837 claim.

4. MSP Claims When There is More than One Primary Payer and More Than One

Allowed Amount-In an MSP situation, Medicare needs to use a primary payer’s

allowed and paid amounts to calculate the supplemental amount that can be paid by

Medicare. In some cases, a beneficiary is covered by more than one other primary

payer. Each of those other payers must complete adjudication before Medicare can

process those claims. The ASC X12 837 current HIPAA version IGs permit

reporting of payment information from more than one other payer, but not for

reporting of separate allowed amounts at the line or claim level for more than one

payer. As result of this limitation, when there is more than one primary payer, and

the allowed amounts differ, a provider is permitted to submit the claim to Medicare

on paper, with the RA/EOB from each of the primary payers attached.

Except for OTAF claims when there is also more than one primary payer, or if a

provider is small or meets one of the temporary exception criteria, such as

disruption of electricity or communications, no other types of MSP claims, such as

MSP claims when there is only one primary payer, may be submitted to Medicare

on paper. Claims submitted by Medicare beneficiaries.