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Returning Paper Claims Received from Clearinghouses (MM5341)
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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 providers who submit paper claims to clearinghouses for filing with Medicare
Provider Impact
If a clearinghouse submits claims for you on paper (rather than electronically) your payments may be affected. The Administrative Simplification Compliance Act (ASCA) requires that claims a clearinghouse submits to Medicare on your behalf must be submitted electronically. When your carrier or fiscal intermediary (FI) identifies that a clearinghouse has submitted a claim for you on paper, they will return the claim unprocessed to the clearinghouse.
Background
Section 3 of the Administrative Simplification Compliance Act (ASCA), PL 107-105; the implementing regulation at 42 CFR 424; and the Medicare Claims Processing ManualChapter 24, Section 90-90.6 and its exhibits all require (except in limited situations) that you submit claims to Medicare electronically. And, while ASCA regulations do allow you (as a provider) to submit some, or all, claims on paper in very specific and limited instances, HIPAA-covered entities (other than providers) are not eligible for an exemption from these electronic Medicare claim submission requirements.
CR 5341, from which this article is taken, addresses claims that your clearinghouse submits to Medicare on your behalf. To be specific, if you contract with a clearinghouse to send claims to Medicare for you, they are required to submit these claims electronically.
This being said, there is evidence that some clearinghouses are routinely submitting paper claims without the provider’s knowledge. You should be aware that your carriers and FIs, having identified that a provider’s clearinghouse has submitted your claims in paper form, will return them back to the clearinghouse without action.
Additional Information
The official instruction (CR5341) issued to your Medicare contractor (carrier, durable medical equipment regional carrier (DMERC), DME Medicare Administrative Contractor (DME MAC), fiscal intermediary (FI), or Part A/B Medicare Administrative Contractor (A/B MAC)) regarding paper claims that they receive from clearinghouses is located at http://www.cms.hhs.gov/Transmittals/downloads/R247OTN.pdf  on the CMS Web site.
If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  .
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article 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.
MLN Matters Number: MM5341
Pub. 100-20, Transmittal# R247OTN, CR# 5341
Related CR Release Date: November 3, 2006
Effective Date: January 1, 2007
Implementation Date: January 2, 2007
Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including -- “It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot- -and do not forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember, influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.
Posted: 11/10/2006
CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
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