CMS Pub. 100-04, ch. 24, § 90.7.6

in SuperPES Files

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

Costs for FY 2009 and later for ASCA review expenses as delineated are to be included

in the annual operations budget request submitted by the RRB SMAC.

Exhibits of Form Letters

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Exhibit A - Response to a non- “unusual circumstance” waiver request

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Electronic Claim Submission Waiver Request

You recently submitted a request for waiver of the Administrative Simplification and

Compliance Act (ASCA) requirement that claims be submitted electronically to be

considered for Medicare payment. Providers are to self-assess to determine if they meet

the criteria to qualify for a waiver. A request for waiver is to be submitted to a Medicare

contractor only when an “unusual circumstance,” as indicated in b, c or d below applies.

Medicare will not issue a written waiver determination unless b, c or d applies.

ASCA prohibits payment of service and supply claims submitted to Medicare on paper,

except in limited situations that apply either to all of a provider’s claims, only to specified

types of claims or for a limited period as indicated below:

1. Claims submitted by small providers-To qualify, a provider required to use a

CMS-1450 form when submitting claims on paper shall have fewer than 25 full

time equivalent employees (FTEs).A physician, practitioner, or supplier required

to use a CMS-1500 form in a current version when submitting claims on paper

shall have fewer than 10 FTEs. A small provider can elect to submit all, some or

none of their claims electronically;

2. Dental Claims;

3. Claims submitted by participants in a Medicare demonstration project for services

or items covered under that demonstration project when paper claim filing is

required as result of the inability of the HIPAA claim implementation guide to

handle data essential for that demonstration;

4. Roster claims for mass immunizations, such as flu or pneumonia injections--Paper

roster bills cover multiple beneficiaries on the same claim. This exception applies

to providers who do not have an agreement in place with a Medicare contractor

that commits them to electronic submission of mass immunization claims;

5. Claims sent to Medicare when more than one other insurer was liable for payment

prior to Medicare;

6. Claims submitted by providers that rarely treat Medicare patients and that submit

fewer than 10 claims a month to Medicare in total (total of all claims sent to all

Medicare Administrative Contractors (MACs) including the RRB Specialty

Medicare Administrative Contractor. );

7. Claims submitted by beneficiaries;

8. Claims from providers that only furnish services outside of the United States;

9. Claims from providers experiencing a disruption in their electricity or

communication connection that is outside of their control and is expected to last

longer than two days. This exception applies only while electricity or electronic

communication is disrupted; and

10. Providers that can establish that some other “unusual circumstance” exists that

precludes submission of claims electronically.

The Centers for Medicare & Medicaid Services (CMS) interprets an “unusual

circumstance” to be a temporary or long-term situation outside of a provider’s control

that precludes submission of claims electronically and as result, it would be against

equity and good conscience for CMS to require claims affected by the circumstance to be

submitted electronically. Examples of “unusual circumstances” include:

a. Periods when a MAC's claim system might temporarily reject a particular type of

electronically submitted claim, pending system modifications (individual MACs

notify their providers of these situations if they apply);

b. Documented disability of each employee of a provider prevents use of a computer

to enable electronic submission of claims;

c. Entities that can demonstrate that information necessary for adjudication of a type

of Medicare claim that does not involve a medical record or other claim

attachment cannot be submitted electronically using the claim formats adopted

under the Health Insurance Portability and Accountability Act (HIPAA); and

d. Other circumstances documented by a provider, generally in rare cases, where a

provider can establish that, due to conditions outside of the provider’s control, it

would be against equity and good conscience for CMS to enforce the electronic

claim submission requirement.

The request you submitted did not include information to establish that situation b, c or d

applies. You are expected to self-assess to determine if one of the other exceptions or

unusual circumstances applies. If your self-assessment indicates that you do meet one of

those situations, you are automatically waived from the electronic claim submission

requirement while the circumstance is in effect. Your MAC will monitor your

compliance with this ASCA requirement on a post-payment basis.

If your self-assessment does not indicate that exception or waiver criteria apply as listed

above, you shall submit your claims to Medicare electronically. This applies to every

MAC to which you submit claims, including the contractor responsible for processing of

Railroad Medicare claims. The Common Electronic Data Interchange (CEDI) contractor

can supply you with free billing software for submission of Medicare DME claims. Visit

the CEDI Web site at www.ngscedi.com for further information on enrollment for use of

EDI, use of free billing software, and other DME EDI information. There are also

commercial billing software, and billing agent and clearinghouse services available on

the open market that can be used to bill Medicare as well as other payers and may better

meet your needs. Please visit the CEDI Website (www.ngscedi.com) to see a list of

HIPAA-compliant vendor services available to you.

Sincerely,

Contractor Name

Exhibit B - Denial of an “unusual circumstance” waiver request

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Request for Waiver of Electronic Claim Filing Requirement Decision

Your request for waiver of the requirement that Medicare claims be submitted

electronically has been denied. The Administrative Simplification Compliance Act

(ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except

in limited situations. Those situations are:

1. Claims submitted by small providers-To qualify, a provider required to use a

CMS 1450 form when submitting paper claims shall have fewer than 25 full-time

equivalent employees (FTEs), and a physician, practitioner, or supplier required

to use the CMS-1500 form in a current version when submitting claims on paper

shall have fewer than 10 FTEs. A small provider can elect to submit all, some or

none of their claims electronically;

2. Dental Claims;

3. Claims submitted by participants in a Medicare demonstration project for services

or items covered under that demonstration project, when paper claim filing is

required as result of the inability of the HIPAA claim implementation guide to

handle data essential for that demonstration;

4. Roster claims for mass immunizations, such as flu or pneumonia injections--Paper

roster bills cover multiple beneficiaries on the same claim. This exception applies

to providers who do not have an agreement in place with a Medicare contractor

that commits them to electronic submission of mass immunization claims;

5. Claims sent to Medicare when more than one other insurer was liable for payment

prior to Medicare;

6. Claims submitted by providers that rarely treat Medicare patients and that submit

fewer than 10 claims a month to Medicare in total (total of all claims sent to all

MACs including the RRB Specialty Medicare Administrative Contractor);

7. Claims submitted by beneficiaries;

8. Claims from providers that only furnish services outside of the United States;

9. Claims from providers experiencing a disruption in their electricity or

communication connection that is outside of their control and is expected to last

longer than two days. This exception applies only while electricity or electronic

communication is disrupted; and

10. Providers that can establish that some other “unusual circumstance” exists that

precludes submission of claims electronically.

The Centers for Medicare & Medicaid Services (CMS) interprets an “unusual

circumstance” to be a temporary or long-term situation outside of a provider’s control

that precludes submission of claims electronically and as result, it would be against

equity and good conscience for CMS to require claims affected by the circumstance to be

submitted electronically. Examples of “unusual circumstances” include:

a. Periods when a MAC's claim system might temporarily reject a particular type of

electronically submitted claim, pending system modifications (individual MACs

notify their providers of these situations if they apply);

b. Documented disability of each employee of a provider prevents use of a computer

to enable electronic submission of claims;

c. Entities that can demonstrate that information necessary for adjudication of a type

of Medicare claim that does not involve a medical record or other claim attachment

cannot be submitted electronically using the claim formats adopted under the Health

Insurance Portability and Accountability Act (HIPAA); and

d. Other circumstances documented by a provider, generally in rare cases, where a

provider can establish that, due to conditions outside of the provider’s control, it

would be against equity and good conscience for CMS to enforce the electronic claim

submission requirement.

We have determined that you do not meet any of these criteria for waiver of the ASCA

requirement for electronic submission of Medicare claims. ASCA did not establish an

appeal process for waiver denials, but you can re-apply for an “unusual circumstance”

waiver if your situation changes. This decision applies to paper claims you may submit

to any MAC in the United States, including the RRB Specialty Medicare Administrative

Contractor. As you do not qualify for a waiver of the ASCA electronic claim submission

requirement, Medicare will begin to deny paper claims you may submit beginning on the

91st day after the date of this letter.

Waiver applications are only to be submitted to request a waiver if an “unusual

circumstance” applies under b, c or d above. The information submitted with your waiver

request did not indicate that circumstance b, c or d any other exception or waiver criteria

apply in your case. If your self-assessment indicates that an exception condition, other

than b, c or d is met, you are automatically waived from the electronic claim submission

requirement and no request should be submitted to a MAC. MACs will monitor

compliance with the ASCA electronic billing requirements on a post-payment basis.

Paper claims submitted to Medicare that do not meet the exception or unusual

circumstance criteria do not qualify for Medicare payment. The Common Electronic

Data Interchange (CEDI) contractor can supply you with free billing software for

submission of Medicare DME claims. Visit the CEDI Web site at www.ngscedi.com for

further information on enrollment for use of EDI, use of free billing software, and other

DME EDI information. There are also commercial billing software, and billing agent and

clearinghouse services available on the open market that can be used to bill Medicare as

well as other payers and may better meet your needs. Please visit the CEDI Website

(www.ngscedi.com) to see a list of HIPAA-compliant vendor services available to you.

Sincerely,

Contractor Name

Exhibit C - Request for Documentation from Provider Selected for

Review to Establish Entitlement to Submit Claims on Paper

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Review of Paper Claims Submission Practices

A large number of paper claims were submitted under your provider number(s) during

the last calendar quarter. Section 3 of the Administrative Simplification Compliance Act,

P.L. 107-105 (ASCA), and the implementing regulation at 42 CFR 424.32, require that

all initial claims for reimbursement from Medicare be submitted electronically with

limited exceptions. The ASCA amendment to § 1862(a) of the Social Security Act

prescribes that “no payment may be made under Part A or Part B of the Medicare

Program for any expenses incurred for items or services” for which a claim is submitted

in a non-electronic form. This also applies to payments made for beneficiaries who

qualify for Medicare based upon their employment in the railroad industry.

ASCA prohibits submission of paper claims except in limited situations that may apply to

all of a provider’s claims, only to specified types of claims or for a limited period as

indicated below:

1. Claims submitted by small providers-- To qualify, a provider required to use the

Form CMS 1450 when submitting claims on paper shall have fewer than 25 full-time

equivalent employees (FTEs). A physician, practitioner, or supplier required to use a

CMS-1500 form in a current version when submitting claims on paper shall have

fewer than 10 FTEs. A small provider can elect to submit all, some or none of their

claims electronically;

2. Dental claims;

3. Claims submitted by participants in a Medicare demonstration project for services

or items covered under that demonstration project when paper claim filing is required

as result of the inability of the HIPAA claim implementation guide to handle data

essential for that demonstration;

4. Roster claims for mass immunizations, such as flu or pneumonia injections--Paper

roster bills cover multiple beneficiaries on the same claim. This exception applies to

providers who do not have an agreement in place with a Medicare contractor that

commits them to electronic submission of mass immunization claims;

5. Claims sent to Medicare when more than one other insurer was liable for payment

prior to Medicare;

6. Claims submitted by providers that rarely treat Medicare patients and that submit

fewer than 10 claims a month to Medicare in total (total of all claims sent to all

Medicare contractors including the RRB Specialty Medicare Administrative

Contractor ;

7. Claims submitted by beneficiaries;

8. Claims from providers that only furnish services outside of the United States;

9. Claims from providers experiencing a disruption in their electricity or

communication connection that is outside of their control and is expected to last

longer than two days. This exception applies only while electricity or electronic

communication is disrupted; and

10. Providers that can establish that some other “unusual circumstance” exists that

precludes submission of claims electronically.

The Centers for Medicare & Medicaid Services (CMS) interprets an “unusual

circumstance” to be a temporary or long-term situation outside of a provider’s control

that precludes submission of claims electronically and as result, it would be against

equity and good conscience for CMS to require claims affected by the circumstance to be

submitted electronically. Examples of “unusual circumstances” include:

a. Periods when a MAC's claim system might temporarily reject a particular type of

electronically submitted claim, pending system modifications (individual MACs

notify their providers of these situations if they apply);

b. Documented disability of each employee of a provider prevents use of a computer

to enable electronic submission of claims;

c. Entities that can demonstrate that information necessary for adjudication of a type

of Medicare claim that does not involve a medical record or other claim attachment

cannot be submitted electronically using the claim formats adopted under the Health

Insurance Portability and Accountability Act (HIPAA); and

d. Other circumstances documented by a provider, generally in rare cases, where a

provider can establish that, due to conditions outside of the provider’s control, it

would be against equity and good conscience for CMS to enforce the electronic claim

submission requirement.

If you intend to continue to submit paper claims, please respond within 30 calendar days

of the date of this letter to indicate which of the above situations is your basis for

continuing submission of paper claims to Medicare. Include with your response,

evidence to establish that you qualify for waiver of the electronic filing requirement

under that situation. For instance, if you are a small provider, evidence might consist of

copies of payroll records for all of your employees for (specify the start and end dates of

the calendar quarter for which the review is being conducted) that list the number of

hours each worked during that quarter. If you are a dentist, evidence might be a copy of

your license.

If you are in a Medicare demonstration project, evidence might be a copy of your

notification of acceptance into that demonstration. If you are a mass immunizer,

evidence might be a schedule of immunization locations that indicates the types of

immunizations furnished. If you experienced an extended disruption in communication

or electrical services, evidence might consist of a copy of a newspaper clipping

addressing the outage. If the paper claims were submitted because this office notified

you of a system problem preventing submission of these claims electronically, please

note that in your response.

If your continuing submission of paper claims is the result of medical restrictions that

prevent your staff from submitting electronic claims, evidence would consist of

documentation from providers other than yourself to substantiate the medical conditions.

If you obtained an unusual circumstance waiver, evidence would be a copy of your

notification to that effect from this office or the Centers for Medicare & Medicaid

Services.

Providers that received waivers for a specific claim type are still required to submit other

claims electronically unless they meet another criterion, e.g., small provider, all staff

have a disabling condition that prevents any electronic filing, claims are for dental

services, or if they otherwise qualify for a waiver under a situation that applies to all of

their claims.

If you cannot provide acceptable evidence to substantiate that you are eligible under the

law to continue to submit paper claims to Medicare, we will begin to deny all paper

claims you submit to us effective with the 91st calendar day after the date of this notice.

ASCA did not establish an appeal process for denial of paper claims in this situation, but

you may qualify for a waiver at a later date if your situation changes. Please contact this

office if your situation changes. This decision applies to paper claims you may submit to

any MAC in the United States, including the Railroad Retirement Board Specialty

Medicare Administrative Contractor.

If in retrospect, you realize that you do not qualify for continued submission of paper

claims, you have a number of alternatives to consider for electronic submission of your

claims to Medicare. The Common Electronic Data Interchange (CEDI) contractor can

supply you with free billing software for submission of Medicare DME claims. Visit the

CEDI Web site at www.ngscedi.com for further information on enrollment for use of

EDI, use of free billing software, and other DME EDI information. There are also

commercial billing software, and billing agent and clearinghouse services available on

the open market that can be used to bill Medicare as well as other payers and may better

meet your needs. Please visit the CEDI Website (www.ngscedi.com) to see a list of

HIPAA-compliant vendor services available to you.

Sincerely,

Contractor

Exhibit D - Notice that paper claims will be denied effective with the 91st

calendar day after the original letter as result of non-response to that

letter

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Review of Paper Claims Submission Practices

Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L. 107-105

and the implementing regulation at 42 CFR 424.32, require that all initial claims for

reimbursement from Medicare be submitted electronically, with limited exceptions. The

ASCA amendment to § 1862(a) of the Social Security Act prescribes that “no payment

may be made under Part A or Part B of the Medicare Program for any expenses incurred

for items or services” for which a claim is submitted in a non-electronic form.

Our records indicate that you are submitting paper claims to Medicare and did not

respond to our initial letter requesting evidence to establish that you qualify for

submission of paper claims to Medicare. Nor do we have information available to us that

would substantiate that you meet any of the limited exceptions that would permit you to

legally submit paper claims to Medicare.

Consequently, as noted in the initial letter as well as in information issued providers

when this ASCA requirement was put into effect, any Medicare paper claims you submit

more than 90 calendar days from the date of the initial letter requesting evidence to

substantiate your right to submit paper claims will be denied by Medicare. ASCA did not

establish an appeal process for denial of paper claims in this situation, but you may

qualify for a waiver at a later date if your situation changes. Please contact this office if

your situation changes. This decision applies to paper claims you may submit to any

Medicare contractor in the United States, including the RRB Specialty Medicare

Administrative Contractor.

If you did not respond because you realized that you do not qualify for continued

submission of paper claims, you have a number of alternatives to consider for electronic

submission of your claims to Medicare. The Common Electronic Data Interchange

(CEDI) contractor can supply you with free billing software for submission of Medicare

DME claims. Visit the CEDI Web site at www.ngscedi.com for further information on

enrollment for use of EDI, use of free billing software, and other DME EDI information.

There are also commercial billing software, and billing agent and clearinghouse services

available on the open market that can be used to bill Medicare as well as other payers and

may better meet your needs. Please visit the CEDI Website (www.ngscedi.com) to see a

list of HIPAA-compliant vendor services available to you.

Sincerely,

Contractor Name

Exhibit E - Notice that paper claims will be denied effective with the 91st

calendar day after the original letter as result of determination that the

provider is not eligible to submit paper claims.

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Review of Paper Claims Submission Practices

Section 3 of the Administrative Simplification Compliance Act, Pub.L.107-105 (ASCA),

and the implementing regulation at 42 CFR 424.32, require that all initial claims for

reimbursement from Medicare be submitted electronically, with limited exceptions. The

ASCA amendment to § 1862(a) of the Social Security Act prescribes that “no payment

may be made under Part A or Part B of the Medicare Program for any expenses incurred

for items or services” for which a claim is submitted in a non-electronic form.

We have reviewed your response to our letter requesting that you submit evidence to

substantiate that you qualify for submission of paper claims under one of the exception

criteria listed in that letter. Upon review, we determined that you do not meet the paper

claims waiver/exception criteria as stated in our prior letter. ASCA did not establish an

appeal process for denial of paper claims in this situation, but you may qualify for a

waiver at a later date if your situation changes. Please contact this office if such a change

in your situation occurs. This decision applies to paper claims you may submit to any

Medicare contractor in the United States, including the RRB Specialty Medicare

Administrative Contractor.

Consequently, any Medicare paper claims you submit on or after the 91st calendar day

from the date of the letter requesting evidence of your eligibility to continue to submit

paper claims will be denied by Medicare.

You have a number of alternatives to consider for electronic submission of your claims to

Medicare. The Common Electronic Data Interchange (CEDI) contractor can supply you

with free billing software for submission of Medicare DME claims. Visit the CEDI Web

site at www.ngscedi.com for further information on enrollment for use of EDI, use of free

billing software, and other DME EDI information. There are also commercial billing

software, and billing agent and clearinghouse services available on the open market that

can be used to bill Medicare as well as other payers and may better meet your needs.

Please visit the CEDI Website (www.ngscedi.com) to see a list of HIPAA-compliant

vendor services available to you.

Sincerely,

Contractor Name

Exhibit F - Notice that determination reached that the provider is

eligible to submit paper claims.

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Review of Paper Claim Submission Practices

Thank you for your response to our previous letter regarding the prohibition against the

submission of paper claims to Medicare. Based on the information you supplied, we

agree that you meet one or more exception criteria to the requirements in §3 of the

Administrative Simplification Compliance Act (ASCA), Pub.L.107-105, and the

implementing regulation at 42 CFR 424.32, that require that all initial claims for

reimbursement from Medicare be submitted electronically, with limited exceptions.

If your situation changes to the point where you no longer meet at least one of the

criteria, you will be required to begin submission of your claims electronically by the 91st

calendar day after that change in your status.

Although you are not required to submit claims electronically at the present time, you are

encouraged to do so. The Common Electronic Data Interchange (CEDI) contractor can

supply you with free billing software for submission of Medicare DME claims. Visit the

CEDI Web site at www.ngscedi.com for further information on enrollment for use of

EDI, use of free billing software, and other DME EDI information. There are also

commercial billing software, and billing agent and clearinghouse services available on

the open market that can be used to bill Medicare as well as other payers and may better

meet your needs. Please visit the CEDI Website (www.ngscedi.com) to see a list of

HIPAA-compliant vendor services available to you.

Sincerely,

Contractor Name

Exhibit G - Notice from the Railroad Retirement Board Specialty

Medicare Administrative Contractor (RRB SMAC) to a Provider that

Has Just Begun to Submit Claims that Paper Claims Submitted by that

Provider Will be Denied

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Denial of Paper Claim Submission Practices

You recently began to treat one or more Railroad Medicare beneficiaries and began to

submit claims to us for the first time. In the process of establishing a record in our files

to indicate that you are eligible to submit Medicare claims, we obtained a copy of your

non-RR Medicare enrollment information. That record indicates that you are required to

submit your Medicare claims electronically to at least one other Medicare Administrative

Contractor and does not indicate that you were issued a waiver to permit submission of

paper Medicare claims. Section 3 of the Administrative Simplification Compliance Act

(ASCA), Pub.L.107-105, and the implementing regulation at 42 CFR 424.32, require that

all initial claims for reimbursement from Medicare be submitted electronically, with

limited exceptions. The ASCA amendment to § 1862(a) of the Act prescribes that “no

payment may be made under Part A or Part B of the Medicare Program for any expenses

incurred for items or services” for which a claim is submitted in a non-electronic form.

ASCA did not differentiate among Medicare contractors or between Railroad and non-Railroad Medicare for application of the electronic claim submission requirement or

exceptions to that requirement. As result, we will begin to deny any paper claims you

submit to us for Railroad Medicare beneficiaries unless you are able to establish that you

meet one or more of the following exceptions to this ASCA requirement:

1. Claims submitted by small providers-- To qualify, a physician, practitioner, or

supplier required to use a CMS-1500 form in a current version when submitting

claims on paper shall have fewer than 10 full-time equivalent employees (FTEs).

A small provider can elect to submit all, some or none of their claims

electronically;

2. Dental claims;

3. Claims submitted by participants in a Medicare demonstration project for services

or items covered under that demonstration project when paper claim filing is

required as result of the inability of the HIPAA claim implementation guide to

handle data essential for that demonstration;

4. Roster claims for mass immunizations, such as flu or pneumonia injections--Paper

roster bills cover multiple beneficiaries on the same claim. This exception applies

to providers who do not have an agreement in place with a Medicare contractor

that commits them to electronic submission of mass immunization claims;

5. Claims sent to Medicare when more than one other insurer was liable for payment

prior to Medicare;

6. Claims submitted by providers that rarely treat Medicare patients and that submit

fewer than 10 claims a month to Medicare in total (total of all claims sent to all

Medicare contractors including the RRB Specialty Medicare Administrative

Contractor );

7. Claims submitted by beneficiaries;

8. Claims from providers that only furnish services outside of the United States;

9. Claims from providers experiencing a disruption in their electricity or

communication connection that is outside of their control and is expected to last

longer than two days. This exception applies only while electricity or electronic

communication is disrupted; and

10. Providers that can establish that some other “unusual circumstance” exists that

precludes submission of claims electronically.

The Centers for Medicare & Medicaid Services (CMS) interprets an “unusual

circumstance” to be a temporary or long-term situation outside of a provider’s control

that precludes submission of claims electronically and as result, it would be against

equity and good conscience for CMS to require claims affected by the circumstance to be

submitted electronically. Examples of “unusual circumstances” include:

a. Periods when a Medicare contractor’s claim system might temporarily reject a

particular type of electronically submitted claim, pending system modifications

(individual Medicare claims processing contractors notify their providers of these

situations if they apply);

b. Documented disability of each employee of a provider prevents use of a computer

to enable electronic submission of claims;

c. Entities that can demonstrate that information necessary for adjudication of a type

of Medicare claim that does not involve a medical record or other claim attachment

cannot be submitted electronically using the claim formats adopted under the Health

Insurance Portability and Accountability Act (HIPAA); and

d. Other circumstances documented by a provider, generally in rare cases, where a

provider can establish that, due to conditions outside of the provider’s control, it

would be against equity and good conscience for CMS to enforce the electronic claim

submission requirement.

If you intend to continue to submit paper claims, please respond within 30 calendar days

of the date of this letter to indicate which of the above situations is your basis for

continuing submission of paper claims to us. Include with your response, evidence to

establish that you qualify for waiver of the electronic filing requirement under that

situation. For instance, if you are a small provider, evidence might consist of copies of

payroll records for all of your employees for (specify the start and end dates of the

calendar quarter for which the review is being conducted) that list the number of hours

each worked during that quarter. If you are a dentist, evidence might be a copy of your

license.

If you are in a Medicare demonstration project, evidence might be a copy of your

notification of acceptance into that demonstration. If you are a mass immunizer,

evidence might be a schedule of immunization locations that indicates the types of

immunizations furnished. If you experienced an extended disruption in communication

or electrical services, evidence might consist of a copy of a newspaper clipping

addressing the outage. If the paper claims were submitted because this office notified

you of a system problem preventing submission of these claims electronically, please

note that in your response.

If your continuing submission of paper claims is the result of medical restrictions that

prevent your staff from submitting electronic claims, evidence would consist of

documentation from providers other than yourself to substantiate the medical conditions.

If you obtained an unusual circumstance waiver, evidence would be a copy of your

notification to that effect from this office or the Centers for Medicare & Medicaid

Services.

Providers that received waivers for a specific claim type are still required to submit other

claims electronically unless they meet another criterion, e.g., small provider, all staff

have a disabling condition that prevents any electronic filing, claims are for dental

services, or if they otherwise qualify for a waiver under a situation that applies to all of

their claims.

If you cannot provide acceptable evidence to substantiate that you are eligible under the

law to continue to submit paper claims to us, we will begin to deny all paper claims you

submit to us effective with the 91st calendar day after the date of this notice. ASCA did

not establish an appeal process for denial of paper claims in this situation, but you may

qualify for a waiver at a later date if your situation changes. Please contact this office if

your situation changes.

You have a number of alternatives to consider for electronic submission of your claims to

Medicare. Commercial software, and billing agent and clearinghouse services are

available on the open market that can be used to bill us as well as other payers. Please

visit (contractor shall insert the URL for vendor information) to see a list of HIPAA-compliant vendor services available in your state. Some providers have reported that

their software vendor or clearinghouse charges a substantial additional amount to allow a

provider to submit Railroad Medicare claims electronically. Please contact this office if

this situation also applies in your case. This office can supply you with free billing

software for submission of Medicare claims. See (contractor shall insert the URL where

information is located on their free billing software, the amount of any handling charge

for issuance, how to obtain further information, and the EDI Enrollment Agreement

which will need to be completed for further information on enrollment for use of EDI,

use of free billing software or other EDI information.

Sincerely,

Contractor Name

Exhibit H - Notice from the Railroad Retirement Board Specialty MAC

to a Provider with a Pre-Established Record in PES that Paper Claims

Will Be Denied as Result of the Requirement that a Provider Submit

Claims to One or More Other Medicare Contractors Electronically

(Rev. 2965, Issued: 05-23-14, Effective: 07-25-14, Implementation: 07-25-14)

Date:

From: MAC (Name and address may appear on masthead)

To: Organizational Name of Provider and Mailing Address

Subject: Review of Paper Claim Submission Practices

Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L.107-105,

and the implementing regulation at 42 CFR 424.32, require that all initial claims for

reimbursement from Medicare be submitted electronically, with limited exceptions. The

ASCA amendment to § 1862(a) of the Act prescribes that “no payment may be made

under Part A or Part B of the Medicare Program for any expenses incurred for items or

services” for which a claim is submitted in a non-electronic form. Paper claims will be

denied if submitted by entities determined to be in violation of the statute or this rule.

ASCA did not differentiate among Medicare Administrative Contractors (MACs) or

between Railroad and non-Railroad Medicare for application of the electronic claim

submission requirement or exceptions to that requirement.

We recently discovered that you have been submitting more than 10 Medicare claims per

month on average to one or more other MACs and/or submitting claims to another MAC

electronically. Unless you have been issued a letter by one or more MACs granting you a

waiver of more than 90 days from the ASCA requirement for electronic submission of

your claims, or are now able to establish that you do meet one or more of the criteria for

waiver of this ASCA requirement, you are also required to submit your claims to us for

Railroad beneficiaries electronically. If you have such a letter, or evidence that you do

now qualify for a waiver of this ASCA requirement, please forward a copy of that letter

or evidence to this office to enable us to update our records and permit you to continue to

submit claims to us on paper if you choose.

ASCA prohibits submission of paper claims except in limited situations that may apply to

all of a provider’s claims, only to specified types of claims or for a limited period as

indicated below:

1. Claims submitted by small providers--To qualify, a provider required to use the

Form CMS-1450 when submitting claims on paper shall have fewer than 25 full-time equivalent employees (FTEs). A physician, practitioner, or supplier required

to use a CMS-1500 form in a current version when submitting claims on paper

shall have fewer than 10 FTEs. A small provider can elect to submit all, some or

none of their claims electronically;

2. Dental claims;

3. Claims submitted by participants in a Medicare demonstration project for services

or items covered under that demonstration project when paper claim filing is

required as result of the inability of the HIPAA claim implementation guide to

handle data essential for that demonstration;

4. Roster claims for mass immunizations, such as flu or pneumonia injections--Paper

roster bills cover multiple beneficiaries on the same claim. This exception applies

to providers who do not have an agreement in place with a MAC that commits

them to electronic submission of mass immunization claims;

5. Claims sent to Medicare when more than one other insurer was liable for payment

prior to Medicare;

6. Claims submitted by providers that rarely treat Medicare patients and that submit

fewer than 10 claims a month to Medicare in total (total of all claims sent to all

MACS including the Railroad Board Specialty Administrative Contractor);

7. Claims submitted by beneficiaries;

8. Claims from providers that only furnish services outside of the United States;

9. Claims from providers experiencing a disruption in their electricity or

communication connection that is outside of their control and is expected to last

longer than two days. This exception applies only while electricity or electronic

communication is disrupted; and

10. Providers that can establish that some other “unusual circumstance” exists that

precludes submission of claims electronically.

The Centers for Medicare & Medicaid Services (CMS) interprets an “unusual

circumstance” to be a temporary or long-term situation outside of a provider’s control

that precludes submission of claims electronically and as result, it would be against

equity and good conscience for CMS to require claims affected by the circumstance to be

submitted electronically. Examples of “unusual circumstances” include:

a. Periods when a MAC's claim system might temporarily reject a particular type of

electronically submitted claim, pending system modifications (individual Medicare

claims processing contractors notify their providers of these situations if they apply);

b. Documented disability of each employee of a provider prevents use of a computer

to enable electronic submission of claims;

c. Entities that can demonstrate that information necessary for adjudication of a type

of Medicare claim that does not involve a medical record or other claim attachment

cannot be submitted electronically using the claim formats adopted under the Health

Insurance Portability and Accountability Act (HIPAA); and

d. Other circumstances documented by a provider, generally in rare cases, where a

provider can establish that, due to conditions outside of the provider’s control, it

would be against equity and good conscience for CMS to enforce the electronic claim

submission requirement.

It is possible that you may previously have contacted this office or had an ASCA

Enforcement Review conducted by this office and were informed that you are eligible to

continue submitting paper claims to this office since you submit fewer than 10 Medicare

claims to us per month. Until recently, we did not have access to ASCA review

information from other MACs that could be used to determine whether you should be

submitting your claims to us electronically. As we do now have access to this type of

information from other MACs, we are required to apply that information to you and to

other providers that submit paper claims to this office.

As you may not have been notified that an ASCA electronic claim submission

requirement that applies to another MAC also affects your submission of paper claims for

Railroad Medicare beneficiaries, we will not begin to deny your paper claims until the

91st day after the date of this letter. This will allow you time to make changes as needed

so you can begin to submit your claims to us electronically by the 91st day.

In the event your situation changes and you feel that you do meet one or more of the

criteria for an exception from the ASCA electronic claim submission requirement, you

should recontact us and any other MAC that made a determination that you do not

currently qualify for an exception. If determined that you do in fact qualify for an

exception at that point, you would have the option to again begin to submit some or all of

your Medicare claims on paper. The type of exception criteria you meet will determine if

the exception applies to only certain types of your claims, all of your claims or applies

only for a temporary period. That would be addressed in the decision notice you would

be sent.

Some providers have reported that their software vendor or clearinghouse charges a

substantial amount to submit Railroad Medicare claims electronically. Please contact this

office if this situation also applies in your case. This office can supply you with free

billing software for submission of Medicare claims. See (contractor shall insert the URL

where information is located on their free billing software, the amount of any handling

charge for issuance, how to obtain further information, and the EDI Enrollment

Agreement which will need to be completed for further information on enrollment for use

of EDI, use of free billing software or other EDI information.

Sincerely,

Contractor Name