Last Modified: 1/3/2018 Location: FL, PR, USVI Business: Part B
Discover the basics of the Administrative Simplification Compliance Act (ASCA)
Q. What is ASCA?
A. It is a law and regulation requiring all initial claims reimbursed under Medicare to be submitted electronically, with limited exceptions.
“Initial claims” are claims submitted for the first time to a Medicare fee-for-service (FFS) contractor or durable medical equipment regional contractor (e.g., previously rejected claims, claims with paper attachments, demand bills, Medicare secondary and non-payment claims). “Initial claims” does not include: adjustments or claim corrections to Part A contractors on previously submitted claims or appeal requests.
Q. When did the implementation of the mandatory electronic submission of Medicare claims begin?
A. It was effective October 16, 2003.
Q. Are you aware you can do a self assessment to determine if you can continue to submit paper claims?
A. You must meet one or more of the situations below.
• Small provider claims -- Medicare considers all providers having fewer than 25 full-time employees (FTEs) and who are required to bill a Medicare Part A contractor to be small; and considers all physicians, practitioners, facilities, or suppliers with fewer than 10 FTEs and who are required to bill a Medicare Part B contractor or durable medical equipment Medicare administrative contractor (DMEMAC) to be small;
• Roster billing of inoculations or immunizations covered by Medicare;
• Claims for payment under a Medicare demonstration project that specifies paper submission;
• Medicare secondary payer (MSP) claims when there is more than one primary payer and one or more of those payers made an "Obligated to accept as payment in full" adjustment;
• Claims submitted by Medicare beneficiaries or Medicare Advantage (MA) plans;
• Dental claims;
• Claims for services or supplies furnished outside of the U.S. by non U.S. providers (not covered by Medicare);
• Disruption in electricity or communication connections outside of a provider's control expected to last more than two business days (e.g., providers affected by Hurricane Katrina);
• Claims from providers who submit fewer than 10 claims per month on average during a calendar year.
Providers are to self-assess to determine if they meet one or more of these situations and should not submit a waiver request when they meet one or more of these situations. Please note that some of these situations are temporary or apply only to certain claims, when the temporary situation expires or when billing other types of claims, providers must submit their claims or those other types of claims electronically, and in the Health Insurance Portability and Accountability Act (HIPAA) standard.
Q. How do providers who no longer qualify for paper claim submission start planning for their transition to electronic claims submission?
A. Not sure where to start? View the article "A Step-By-Step Guide to Getting Started Submitting Electronic Claims."
Q. Where is the regulation found?
A. The Code of Federal Regulations implementing ASCA (Title 42, section 424.32) can be located at 42 CFR 424.32 .
Additional information may be found at CMS’ Electronic billing and EDI transactions page and CMS IOM Publication 100-04 .
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