Discover the basics of the Administrative Simplification Compliance Act (ASCA)

Intro to ASCA

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.

On October 16, 2003 mandatory electronic submission of Medicare claims was implemented 

How to determine eligibility to submit paper claims

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.

No longer qualify for paper claim submission? 

Start planning the transition to electronic claims submission. 

Not sure where to start? View the article "A Step-By-Step Guide to Getting Started Submitting Electronic Claims."

Regulation

The Code of Federal Regulations implementing ASCA (Title 42, section 424.32) can be located at 42 CFR 424.32.

Administrative Simplification Compliance Act (ASCA) enforcement 

Enforcement of the ASCA mandatory electronic claim submission requirement is conducted on a post-payment basis. A provider whose paper claim submission practice is being reviewed to verify one or more of the exception criteria are met for continued submission of paper claims will receive a letter. Please review the letter carefully and take appropriate action timely. 

If you intend to respond to the letter, complete and submit the Administrative Simplification Compliance Act (ASCA) Waiver Request form indicating which of the exception criteria is your basis for continued submission of paper claims, along with supporting information. 

If you determine that you do not qualify for continued paper claims submission and currently submit claims electronically, start planning your transition to electronic claims submission. Not sure where to start? Click link to “A step-by-step guide to getting started submitting electronic claims.”

Administrative Simplification Compliance Act (ASCA) enforcement unusual circumstance waiver request

This article is based on change request (CR) 10559 which reduces confusion and clarifies the ASCA waiver process guidelines found in the Medicare Claims Processing Manual 100-04, Chapter 24, Section 90.

A provider may submit a waiver request to their MAC claiming an “unusual circumstance” outside of their control prevents the submission of electronic claims. It is the responsibility of the provider to submit the appropriate documentation including the following information:

• Provider name
• NPI
• PTAN
• Practice location address
• Valid email address
• Phone number
• Signature of provider’s authorized or delegated official as reported in the CMS-855 enrollment application

This information will be used to establish the validity of the request. Requests received without documentation, and the above stated information, will be denied by First Coast. If First Coast agrees the waiver request has merits, First Coast will send the request to the CMS for review and issuance of a final decision.

If First Coast does not consider the request as an “unusual circumstance”, and does not recommend CMS’ approval, First Coast will issue a response to the provider.

If a provider feels their situation merits an unusual circumstance waiver request, the provider may submit their request to by completing the Administrative Simplification Compliance Act (ASCA) Waiver Request form.

Additional information regarding the Administrative Simplification Compliance Act can be found at: https://www.cms.gov/medicare/coding-billing/electronic-billing