Content Section
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Medical Review Matching of Electronic Claims and Additional Documentation in the Medical Review Process
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MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Provider Types Affected
All Medicare physicians, providers, and suppliers
Provider Action Needed
Impact to You
Other than certain limited exceptions, such as for providers that employ very few employees, the Centers for Medicare & Medicaid Services (CMS) currently instructs all initial claims to be filed electronically. This is true even when the claim will be subjected to prepayment medical review.
What You Need to Know
Generally, Medicare contractors (carriers, durable medical equipment regional carriers (DMERCs), and fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs), cannot require or permit the voluntary submission of paper claims. If any supporting paper documentation is necessary for medical review, it can only be solicited by the contractor and submitted through the Additional Documentation Request (ADR) or alternate contractor process that permits matching. This supporting documentation must be submitted separately from an electronic claim, at the contractors’ request. Exception: At their discretion, some contractors accept unsolicited paper supporting documentation, if they can match the electronic claim and paper documentation.
What You Need to Do
File initial claims electronically when subjected to prepayment medical review unless you are in an “excepted” category. Unless your contractor informs you that they accept supporting paper documentation with the electronic claim, submit all supporting documentation through the regular ADR process, or alternate contractor process that permits matching.
Background
Although Medicare contractors may use any information they deem necessary to make a prepayment or post-payment claim review determination, contractors may not require providers or suppliers to file initial claims on paper to Medicare when the claim requires additional documentation. The Administrative Simplification Compliance Act requires providers, with very few exceptions, to submit claims electronically.
Medicare contractors may not require or request of any provider the submission of supporting documentation with the initial claim(s) through contractor developed forms, local policies, or any other communication with providers. Medicare contractors may only request supporting documentation through the ADR process or alternate contractor process that enables matching of the documentation to the initial claim.
Additional Information
The Medicare Claims Processing Manual, Chapter 24, Section 90, contains information regarding the limited circumstances under which your contractor may request paper claims. The manual is available at http://www.cms.hhs.gov/manuals/104_claims/clm104c24.pdf  on the CMS Web site.
The official instruction issued to your carrier/intermediary/DMERC/RHHI regarding this change may be found by going to http://www.cms.hhs.gov/Transmittals/  on the CMS Web site. From that Web page, look for CR4052 in the CR NUM column on the right, and click on the file for that CR.
You may also wish to refer to Medlearn Matters article MM3440 on the requirements to submit claims electronically. That article is available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3440.pdf on the CMS Web site.
If you have any questions, contact your carrier/DMERC/FI/RHHI at their toll free number, which is available at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
Medlearn Matters articles are prepared as a service to the public and are not intended to grant rights or impose obligations. Medlearn Matters articles may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.
Related Change Request (CR) #: 4052
Medlearn Matters Number: MM4052
Related CR Release Date: November 10, 2005
Related CR Transmittal #: 131
Effective Date: February 10, 2005
Implementation Date: February 10, 2005
Posted: 11/23/2005
CPT codes, descriptions, and
other data only are copyright 2005 American Medical Association
(or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS Apply.
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