CMS Pub. 100-04, ch. 24, § 90.5.3

A. Identification of Those Providers to be Reviewed

Separate funding will no longer be issued for these reviews annually. Each A/B

MACs (B) and DME MAC shall conduct an ASCA review annually of 20% of those

providers still submitting paper bills.

The following providers will be included in the quarterly report, but contractors are

not to select a provider for review that quarter if:

• A prior quarter review is underway and has not yet been completed for that

provider (start date of prior review is listed in the report but not yet an

enforcement decision effective date);

• The provider has been reviewed within the past two years, determined to be a

“small” provider, and there is no reason to expect the provider’s “small” status

will change for at least two years (provider file past ASCA review result was

“SM” and completion date of that review is less than 24 months in the past);

or

• Fewer than 30 paper claims were submitted by the provider for the quarter.

When calculating 20% of providers still submitting paper claims, exclude those

providers mentioned above who will not be considered for an ASCA review. For

example, the A/B MAC (B) or DME MAC receives claims for 3,200 providers but

only 2,000 of those submit any paper claims, and 1,800 submit more than 30 paper

claims per quarter. 600 of that 1,800 have been reviewed within 2 years of the

quarter in which a Medicare contractor is now determining which providers should be

reviewed during that quarter and determined to be small. 75 of the paper billers in the

quarterly report had reviews begin the prior quarter which are still open. That leaves

a balance of 1,125 providers who could be subject to an ASCA review during the

current quarter. 1,125 is the total of the universe of providers that are candidates for

review during the current quarter and the number of the universe to be reported to

CMS in the A/B MACs (B) or DME MACs monthly ASCA report. 20% of 1,125 is

225 and ¼ of 225 is 56 ¼. That contractor is expected to begin at least 56 new ASCA

reviews during the current quarter. By the end of the fiscal year (FY), that A/B MAC

(B) or DME MAC is expected to have begun ASCA reviews of the average of the

provider universe totals for the quarters multiplied by 20%. In this example, if 1,125

providers was the average number of providers considered for ASCA review for the 4

quarters of the FY and the contractor began ASCA reviews of 225 of those providers

by the end of the FY, that A/B MAC (B) or DME MAC will have met the 20% target

for that FY.

1. A/B MAC (B) and DME MAC - Specific Selection Requirements-A/B MACs

(B) and DME MACs will determine the best candidates for review from the

quarterly report and will complete the block/field to identify the selected

providers in the quarterly report and trigger release of Exhibit letter C to those

providers. (The A/B MACs (B) and DME MACs must furnish the appropriate

URLs for the last paragraph of the letter.) Select candidates as follows:

a. Two-thirds from Part 1 providers beginning with those that have the largest

number of paper claims and issuing letters in descending order; and

b. One third from Part 2 providers also beginning with those that have the

largest number of paper claims and issuing letters in descending order.

NOTE: In the case of a provider that submits claims under more than one PIN or NSC

number, all of which are under the same TIN, and for which there are multiple entry lines

in the quarterly report, the A/B MAC (B) and DME MAC shall combine the number of

paper claims submitted under each of those PINs/NSCs when determining which

providers to be selected for review. For ASCA evaluation purposes, consider all of those

paper claims as submitted by the same provider even though under different PINs or

NSCs. Complete the block/field for each of the provider’s lines in that case, but apply

the same review result for each of the affected PINs/NSCs recorded for that provider. In

terms of number of reviews conducted, a review that involves multiple PINs or NSCs for

the same provider is to be treated individually and multiple copies of letter C are to be

issued.

If an A/B MAC (B) and DME MAC exhausts the Part 1 list and still has additional

reviews to conduct in the quarter, the contractor is to increase the number of initial

review letters sent to Part 2 providers. If the Part 2 list is also exhausted for the

quarter, and the contractor still has additional reviews to initiate, the contractor will

begin to send initial review letters to those providers in Part 3 of the shared system

quarterly report, again having letters issued in descending order beginning with those

providers with the largest numbers of paper claims.

A/B MACs (B) and DME MACs are to complete selection of providers to be

reviewed by the end of the second month of each quarter.

B. Conducting the Reviews

If a provider responds to letter C or D (whether triggered by an A/B MAC or DME MAC

selection of the provider for review in the quarterly report or direct issuance of the letters

by an A/B MAC (A)), but does not establish eligibility to submit paper claims, the A/B

MAC (A) shall notify the shared system to begin denying paper claims submitted by that

provider beginning on the 91st day after release of letter C and shall issue letter E. The

A/B MAC or DME MAC shall enter ASCA review result code NE in the shared system

ASCA review result field (see §90.5.2). This will trigger the shared system to have

Exhibit letter E released by the contractor’s correspondence system.

If a provider’s response to letter C or D establishes that the provider is eligible to submit

paper claims to Medicare, the A/B MAC (A) shall issue provider letter F, and the A/B

MAC or DME MAC shall enter ASCA review result code SM, WA or UC (see §90.5.2

as appropriate in the ASCA review result field). This will trigger MCS or VMS to have

letter F released.

A/B MACs or DME MACs have authority to delay imposition of denial of paper claims

for up to 30-days if the provider responds to letter C or D and indicates all changes

needed to submit their claims electronically cannot be completed by the 90th day after

letter C, but will be completed within 30 additional days. An A/B MAC or DME MAC

should approve an extension request of up to 30 days, if the A/B MAC or DME MAC has

no reason to suspect the provider may not complete the changes by the specified date.

When an extension is approved, an A/B MAC (A) must reset the effective date of paper

claim denials as needed so FISS does not begin to deny paper claims from that provider

prior to expiration of the extension period. An A/B MAC or DME MAC must enter the

new effective date (CCYYMMDD) when MCS or VMS is to begin denying paper claims

in the paper claim denial date field (see §90.5.2) and also enter NE in the ASCA review

result screen/field. MCS or VMS will begin to deny the provider’s paper claims on the

date entered.

If based on prior experience with the provider or knowledge of the extent of the changes

the provider must make, the A/B MAC or DME MAC has reason to doubt the ability of

the provider to complete the necessary changes by the 120th day, the MAC is to deny a

provider’s extension request. The A/B MAC (A) shall immediately notify FISS to begin

denying paper claims from that provider beginning on the 91st day after issuance of letter

C. The A/B MAC or DME MAC shall enter NE in the ASCA review result screen/field;

MCS or VMS shall begin to deny that provider’s paper claims on the 91st day after letter

C was triggered.

The A/B MAC or DME MAC does not have authority to approve more than one 30-day

extension during the same review. A/B MACs or DME MACs must contact

CMS/OIT/AMG/Division of Shared Systems Management (DSSM) if a contractor

representative thinks a provider’s request for an extension beyond the 120th day should be

approved. If a c A/B MAC or DME MAC does not endorse an extension request beyond

the 120th day, the contractor should deny the request. The A/B MAC or DME MAC shall

enter NE in the ASCA review result screen/field. If DSSM approval is requested by a

contractor and DSSM does approve an extension, A/B MACs or DME MACs are to

follow the requirements in the prior paragraph concerning resetting of the effective date

for denial of that provider’s paper claims.

When A/B MACs or DME MACs finish each provider’s ASCA review, the A/B MAC or

DME MAC must enter the outcome to the provider file (see §90.5.2), except where

identified as shared system responsibility, as well as enter the specific unusual

circumstance when result code UC applies.

The group code CO (provider financial liability) is to be used with reason code 96 (non-covered charges), remark code M117 (Not covered unless submitted by electronic claim),

and remark code MA44 (No appeal rights). Adjudicative decision based on law for the

entire billed amount in the remittance advice sent to the provider for claims when denied

as submitted on paper.

If a provider is a candidate for an ASCA enforcement review and the provider is also

undergoing a fraud or abuse investigation, the A/B MAC or DME MAC has discretion to

exclude that provider from the ASCA enforcement review that quarter if it could interfere

with the fraud/abuse investigation, or alternately, may combine the ASCA review with

the fraud/abuse investigation. If an ASCA enforcement review is not conducted due to

possible interference, and the provider is subsequently cleared of fraud or abuse, the

ASCA enforcement review is to be conducted when that fraud/abuse investigation is

completed.

Most types of ASCA exceptions/waivers apply to individual claim types only, or to

submission of paper claims for temporary periods. If a provider is selected for ASCA

review, and the contractor determines that most of the paper claims submitted for that

provider for that period:

1. Were for MSP claims when there is more than one primary payer, or for mass

inoculations, or similar types of claims allowed to be submitted on paper; or

2. Were submitted on a temporary basis as result of power and communication

disruption resulting from a natural disaster or similar problem outside the control

of the provider; AND

3. The number of paper claims submitted for the provider during that quarter that did

not meet such criteria would not have been high enough to have resulted in

selection of that provider for ASCA review in the absence of the excepted/waived

claims, the contractor is to terminate that review. THEN,

The A/B MAC or DME MAC must enter provider ASCA review result WA (see §90.5.2)

to trigger Exhibit letter F, and an A/B MAC (A) must issue letter F.

NOTE: WA or issuance of letter F to a provider that is being waived for a reason other

than the number of FTEs employed does not preclude the provider from A/B MAC, or

DME MAC selection for review during subsequent quarters.

A/B MACs and DME MACs are not to maintain a provider FTE database, or establish a

separate database of waived providers, unless an “unusual situation” waiver decision is

made as result of a provider’s request for approval of a waiver (see 90.3.2), or as result of

an ASCA review and either A/B MACs or DME MACs provider ASCA determination

WA or UC (see §90.5.1) applies, or an A/B MACs (A) has issued letter F for other than

the small provider exception.

Each A/B MAC or DME MAC will maintain a local Excel spreadsheet of “unusual

situation” waivers and requests with column headings for the name, address, legacy and

NPI provider number, whether a requested “unusual circumstance” waiver was approved

or denied, the effective and termination dates for an approval (if applicable), and the

unusual circumstance identified in the request.

A/B MACs and DME MACs must be able to submit this spreadsheet to CMS when

requested or could be asked to submit data from the spreadsheet in a report to CMS.

Provider entries in this spreadsheet shall be retained for the same period that A/B MACs

and DME MACs are required to retain claims.

C. Post-Review Actions

If following the start of paper claim denials, a provider subsequently submits

documentation to establish that they actually had met criteria for submission of paper

claims by that 91st day, the A/B MAC or DME MAC must enter SM, WA or UC as

appropriate in the shared system ASCA review result field. This will trigger the shared

system to have Exhibit letter F issued and will eliminate further paper claim denials for

the provider. An A/B MAC (A) must notify FISS to terminate denial of that provider’s

paper claims. The shared system is not to reprocess any paper claims previously denied

as on paper for that provider unless the provider resubmits those claims.

If a provider submits documentation to establish eligibility to submit paper claims but

that eligibility is effective after the 91st day, the A/B MAC or DME MAC shall enter the

date when the provider actually became eligible to submit paper claims in the appropriate

field in the shared system ASCA review result screen (see §90.5.2). There is no

corresponding A/B MAC (A) process for this, but it is considered unlikely that this

situation would occur with an institutional provider. If a provider resubmits denied

claims, services furnished on or after the date of eligibility to submit paper claims may be

paid but services furnished after the 90th day through the day before the provider became

eligible to submit paper claims may not be paid. They must be denied as furnished

during a period for which the provider was required to bill Medicare electronically.