CMS Pub. 100-04, ch. 24, § 90.6

Medicare contractors were required to include information on their provider Web site and

in a newsletter by April 2004 to notify providers of/that:

1. Providers that do not qualify for a waiver as small and that do not meet any of the

remaining exception or waiver criteria must submit their claims to Medicare

electronically;

2. Small provider criteria and that small providers are encouraged to submit as many

of their claims electronically as possible;

3. FTE definition and calculation methodology;

4. Exception criteria;

5. Unusual circumstance criteria;

6. Self-assessment requirements;

7. Process for submission of an unusual circumstance waiver;

8. Additional claims, such as certain claim types not supported by free billing

software, that must continue to be submitted on paper pending any contractor or

shared system modifications to enable those claims to be submitted electronically;

9. Submission of paper claims constitutes an attestation by a provider that at least one

of the paper claim exception or waiver criterion applies at the time of submission;

10. Repercussions of submitting paper claims when ineligible for submission of paper

claims;

11. Post-payment monitoring to detect providers that submit unusually high numbers

of paper claims for further investigation; and

12. Waiver request submitted by providers should include the providers’ name,

address, contact person, the reason for the waiver, why the provider considers

enforcement of the electronic billing requirement to be against equity and good

conscience, and any other information the contractor deems appropriate for

evaluation of the waiver request.

90.7 - Application of Electronic Data Interchange Enrollment

Information and ASCA Enforcement Review Decisions from Other

Medicare Contractors to the Same Providers When They Bill the

Railroad Retirement Board Specialty MAC (RRB SMAC)

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

ASCA did not differentiate among Medicare contractors or between Railroad (RR) and

non-RR Medicare for application of the electronic billing requirement. Section 90.3.1 of

this chapter indicates that a provider that submits fewer than 10 claims to Medicare per

month on average (fewer than 120 claims per year) is permitted to continue to submit

paper claims. As result of the distribution of RR retirees though, it is not unusual for a

single provider to only treat a small number of RR Medicare patients and to submit fewer

than 10 claims to the RRB SMAC per month. The same providers that treat RR

Medicare patients also treat non-RR Medicare beneficiaries however, and in most cases

do submit more than 10 claims per month in total to one or more non-RR Medicare

contractors. As result, when selecting providers for an ASCA Enforcement Review, the

RRB SMAC shall not exclude a provider from consideration for review simply because

the quarterly ASCA report indicates the provider submitted fewer than 10 claims to the

RRB SMAC. In a departure from the rule as it applies to non-RRB SMAC Medicare

contractors, submission of fewer than 10 claims per month to the RRB SMAC does not

automatically qualify a provider for waiver of the electronic claims submission

requirement.

Providers that submit paper claims to multiple Medicare MACs, including both RR and

non-RR MACs, could have an ASCA Enforcement Review conducted by each of those

contractors. If a non-RR Medicare MAC determines that a provider does not meet any

criteria which would permit that provider to continue to submit Medicare claims on paper

and notifies a provider (letter E is triggered) that all paper claims submitted on or after a

specific date will be denied, that same decision is to be applied to that provider if

submitting paper claims to the RRB SMAC regardless of whether that provider would

submit 10 or more paper claims to the RRB SMAC monthly.

Provider enrollment information from non-RR MACs is sent to the RRB SMAC weekly

by the MCS maintainer in a Provider Enrollment System file called SuperPES. As a

condition for submission of claims to the RRB SMAC, a provider must first enroll for

submission of claims to non-RR Medicare. The RRB SMAC uses SuperPES to

determine whether any provider that sends them a claim, but that does not have a record

in the RR provider enrollment system (PES), is already enrolled in non-RR Medicare. If

so, the RRB SMAC then uses the SuperPES information to establish a record for that

provider in the RR PES file, or if not, rejects those claims as there is no indication that

provider has enrolled in Medicare.

SuperPES is manually searched by RRB SMAC representatives. It would be difficult and

possibly impossible to automatically update PES due to the differences in RR and non-RR legacy provider numbers. Addition of NPIs may not appreciably improve the ability

to make one to one matches since providers can obtain more than one NPI or fewer NPIs

than legacy identifiers. Although supplemental information is submitted on claims that

can often be used to match between an NPI and a single legacy identifier, there is not as

much supplemental information in the SuperPES and PES files that could be used to help

make a match between the files in the absence of a claim.

SuperPES includes fields (see the date and ASCA decision fields in §90.5.2) for the

reporting of an ASCA review result, the date of that ASCA decision and the NPI

associated with the provider’s non-Railroad PIN. “Multi” is entered in that field if more

than one NPI is associated with a PIN.

The RRB SMAC shall check SuperPES for the availability of ASCA Enforcement

Review information when selecting providers on PES for ASCA Enforcement Reviews,

as well as when first establishing a PES record for a provider. If an ASCA review

decision (NE, SM, WA or UC) is in SuperPES, that decision and the effective date of that

decision in SuperPES must be entered into that provider’s record in PES. In lieu of “NE”

however, the RRB SMAC shall enter “NR” in PES to indicate that the “not eligible”

determination was made by a contractor other than the RRB SMAC. If either “SM,”

“WA” or” UC” applies, the effective date of the decision is the later of the date in

SuperPES when that contractor began the most recent ASCA review or the date the

provider became eligible to submit paper claims when that is later than the date that the

denial of claims began as result of a prior NE/NR decision. A future date may not be

entered in PES for a NE/NR decision. A future NE effective date in SuperPES signifies

that the contractor has not yet completed the ASCA review and that the decision is still

tentative. See §90.7.1 for further use of the ASCA decision codes to determine when to

issue ASCA review letters.

If there is more than one entry in SuperPES for the same provider, perhaps as result of the

provider’s submission of claims to more than one Medicare contractor, the RRB SMAC

shall compare each of those entries that contains an ASCA decision and enter that

decision and that effective date in PES that is the most “negative” in terms of the number

of paper claims that would be submitted to the RMC as result of entry of that decision

and date. The RRB SMAC has discretion to determine which set of ASCA information is

the most negative overall.