CMS Pub. 100-04, ch. 24, § 90.7.1

EDI Enrollment Information from Other Medicare Contractors into

PES

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

To take advantage of the information being added to SuperPES, the RRB SMAC shall do

the following:

• When using SuperPES to establish an initial record in PES for a

provider--If available in SuperPES, the RRB SMAC shall copy any

ASCA review result information and the provider’s ZIP Code, (extended

if available), as well as those data elements that would have been copied in

the past, and include that information in PES. If there is an NE entry in

the ASCA review decision field, the RRB SMAC shall manually issue

letter G to the provider to notify the provider that paper claims submitted

to the RRB SMAC beginning on the 91st day after the date of the letter

will be denied unless the provider can establish eligibility for one of the

ASCA exceptions. See information later in this section on use of ASCA

decision codes in selection of providers to be sent an ASCA Enforcement

review letter. If no evidence has been received by the 45th day after the

date of that letter, MCS shall trigger release of letter D. MCS shall trigger

release of letter E and begin denying paper claims on the 91st day after the

date of letter G as if a normal ASCA review was being conducted, unless

the provider submits documentation that results in cancellation of the

denial by the RRB SMAC.

• When a provider for whom a PES record was previously established

is selected from the shared system’s quarterly paper claim submitters

report to initiate a new ASCA Enforcement Review-- The RRB SMAC

shall look up each selected provider that has been tentatively selected for

an ASCA review in the most recent SuperPES file to see if a record can be

located based upon the information the RRB SMAC has available for that

provider. When able to locate a record, the RRB SMAC shall add any

ASCA review results from another Medicare contractor for that provider

and the ZIP Code (extended if available) for that provider to PES. An

“NE” decision shall be converted to “NR.” See information later in this

section on use of ASCA decision codes in selection of providers to be sent

an ASCA Enforcement Review letter. The RRB SMAC will use the

shared system’s quarterly report to trigger release of letter H to notify the

provider that paper claims they submit beginning on the 91st day after the

date of the letter will be denied. If no response is received after 45 days,

MCS shall trigger release of letter D. If no response is received to letter

D, or there is a response but it will not result in a decision to allow the

provider to continue to submit paper claims, MCS shall trigger release of

letter E and begin denying paper claims submitted following the regular

procedures for an ASCA Enforcement Review.

• If the RRB SMAC learns that a provider that sends paper claims to

the RRB SMAC and sends electronic claims to one or more other

Medicare contractors-When this information comes to the attention of

the RRB SMAC as result of an action other than establishment of an initial

record in PES or selection of a provider for review from the quarterly

ASCA report, the RRB SMAC shall check the provider’s record in

SuperPES and in the last quarterly paper claim submitters report received

from MCS. If there are no ASCA Enforcement Review results in

SuperPES that would preclude initiation of an ASCA Enforcement

Review (see §90.7.2), the RRB SMAC shall use the quarterly report to

trigger release of letter H. MCS shall trigger letters D and E as

appropriate in a regular ASCA Enforcement Review unless the RRB

SMAC cancels denial of the paper claims because the provider responded

and was able to establish grounds for continued submission of paper

claims to the RRB SMAC. If the RRB SMAC has already initiated all

reviews targeted for that quarter, the RRB SMAC may initiate this review

as part of the next quarter’s reviews.

If the ASCA information in SuperPES for a provider indicate that the provider was

determined to be eligible for continued submission of paper claims as result of an ASCA

review, the RRB SMAC shall enter that ASCA exception/waiver decision in PES for

future reference. If a provider alleges that contrary to a NE ASCA review determination

in SuperPES, they do not submit Medicare claims to any MAC electronically and that

provider furnishes a letter from another MAC that indicates an ASCA exception/waiver

determination that is not yet reflected in SuperPES, the RRB SMAC is to enter the

appropriate ASCA decision code in PES for the provider and shall not deny the

provider’s paper claims for ASCA purposes.

In the absence of such a letter however, the RRB SMAC is to assume that providers that

have an NE entry in SuperPES do submit electronic claims to at least one other MAC, do

submit 10 or more claims electronically to Medicare overall and can also submit claims

to the RRB SMAC electronically. The RRB SMAC is to use the most recent MCS

quarterly paper claim submitters report, or if all reviews targeted for that quarter have

already been initiated, the next quarterly paper claim submitters report received to trigger

release of letter H in that situation. MCS shall trigger letters D and E and begin denial of

that provider’s paper claims on the 91st day unless the RMC delays or cancels the denial

action.