Content Section
Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here).
|
Issue 2006-03, March 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
|
Shared Systems Medicare Secondary Payer (MSP) Balancing Edit and Administrative Simplification Compliance Act (ASCA) Enforcement Update
Provider Types Affected
Physicians, suppliers and providers billing MSP claims to Medicare carriers, fiscal intermediaries (FI), durable medical equipment regional carriers (DMERCs) and regional home health intermediaries (RHHIs)
Key Points for Providers
CR4261 makes two key changes to Medicare claims processing as follows:
- First, CR4261 states that inbound MSP claims will be rejected if the paid amounts and the adjusted amounts paid by the primary payer do not equal the billed amounts at the line level and if the claim lacks standard claim adjustment reason codes to identify adjustments performed.
While Medicare may be able to handle such a discrepancy because it does not always use this information, it may pass such claims to other payers. Such other payers may then reject the claims because they do not comply with the 837 version 4010A1 institutional and professional implementation guides. As a result, Medicare will not accept such claims in order to be fully compliant with HIPAA.
- Second, if a provider’s paper claims have been denied due to ASCA electronic claims provision enforcement by Medicare contractors (carriers, FIs, RHHIs, and DMERCs), the provider may resubmit the paper claims if they submit appropriate documentation that establishes that they meet the criteria for submitting paper claims.
Providers have until the ninety-first day after the initial ASCA letter to submit documentation that proves eligibility for submission of paper claims. If a provider establishes eligibility later than the ninety-first day of the initial enforcement letter and then resubmits paper claims, payment will be denied for dates of service between the ninety-first day and the effective date for submission of claims.
Implementation
The implementation date for the instruction is July 3, 2006.
Additional Information
For details of enforcement of the ASCA, please see related Medlearn Matters article MM3440, “Administrative Simplification Compliance Act (ASCA) Enforcement of Mandatory Electronic Submission of Medicare Claims,” at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3440.pdf  on the CMS Web site.
The official instruction on this change, CR4261, may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R831CP.pdf on the CMS Web site.
If you have questions, please contact your carrier/intermediary/DMERC at their toll-free number which may be found at http://www.cms.hhs.gov/apps/contacts/  on the CMS Web site.
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.
For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles.
Pub. 100-4, Transmittal# R831CP, CR# 4261
Medlearn Matters Number: MM4261
Related CR Release Date: February 2, 2006
Effective Date: July 1, 2006
Implementation Date: July 3, 2006
|
