CMS Pub. 100-04, ch. 24, § 90.7.5

The letters that apply to ASCA Enforcement Reviews at the end of this chapter did not

originally refer to application of decisions made by an A/B MAC (B) to a provider when

billing the RRB SMAC. These letters have now been modified to note that an ASCA

Enforcement Review made by one Medicare MAC that a provider does not qualify to

submit claims on paper also applies to that same provider when billing other Medicare

MACs, including the RRB SMAC. Two letters (G and H) have been added specifically

for RRB SMAC use. Letters G and H may not be sent by and do not apply to any

contractor other than the RRB SMAC.

The ASCA regulation indicated that denial of claims because they were not submitted to

Medicare electronically would be applied on a prospective basis. Ninety days is being

allowed prior to denial in letters G and H to allow time for those providers that do not

have software for submission of electronic claims to the RRB SMAC to obtain that

software from their vendor. Addition of a RRB SMAC module to some commercial

electronic claim submission software can reportedly be expensive. As result, wording

has also been included in the letters concerning the Medicare free billing software.

The cost charged by a commercial software vendor for a module to enable claims to be

submitted to the RRB SMAC electronically is not a valid basis for waiver of the

requirement that a provider submit their claims to the RMC electronically. The RRB

SMAC shall encourage a provider who may mention cost to use the RMC’s free billing

software if this would be a more cost effective method of electronic submission of their

claims to the RRB SMAC. The provider shall use either the commercial software of their

choice or the Medicare free billing software and shall begin to submit their claims to the

RRB SMAC electronically if they wish to continue to be paid for services furnished to

RR Medicare beneficiaries.

The ASCA Enforcement Review letters now refer to an ASCA electronic claim

submission requirement made by one MAC as applying to all MACs because that is

actually how ASCA decisions are to be applied. CMS has not enforced this across the

board due to the lack of a vehicle for sharing decisions across contractor lines, other than

in the case of the RRB SMAC. If a vehicle becomes available to do this in the future for

contractors other than the RRB SMAC, CMS will begin to require that this be done.

Sharing of these decisions across the board would require coordination to eliminate the

possibility that more than one contractor could conduct reviews of the same provider at

the same time so this issue would also need to be addressed in any subsequent change

request issued for this purpose.