Administrative Simplification Compliance Act Waiver Application

The Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies that a provider did not bill to Medicare electronically. "Provider" is used in a generic sense here and refers equally to physicians, suppliers, and other health care providers. Providers are required to self-assess to determine whether they meet certain permitted exceptions to this electronic billing requirement. ASCA self-assessable situations are described elsewhere in this section of the CMS web site.

There are also some situations when this electronic billing requirement could be waived for some or all claims, but a provider must obtain Medicare pre-approval to submit paper claims in these situations:
 
• Any situation where a provider can demonstrate that the applicable adopted HIPAA claim standard does not permit submission of a particular type of claim electronically;

  • Disability of all members of a provider's staff prevents use of a computer for electronic submission of claims; and

  • Other rare situations that cannot be anticipated by CMS where a provider can establish that due to conditions outside of their control, it would be against equity and good conscience for CMS to enforce this requirement.

A request for this type of waiver must be sent by letter to the Medicare contractor to which a provider submits claims.

ASCA act self assessment

Administrative Simplification Compliance Act Self Assessment 

The Administrative Simplification Compliance Act (ASCA) prohibits payment of initial health care claims not sent electronically as of October 16, 2003, except in limited situations:

• Small Provider Claims-- The word "provider" is being used generically here to refer to physicians, suppliers, and other providers of health care services. Providers that have fewer than 25 full-time equivalent employees (FTEs) and that are required to bill a Medicare intermediary are considered to be small. Physicians and suppliers with fewer than 10 FTEs and that are required to bill a Medicare carrier or durable medical equipment regional carrier (DMERC) are classified as small. See section 90.1 of Chapter 24 of the Medicare Claims Processing Manual (Pub. 100-04) for more detailed information on calculation of FTE employees and this ASCA requirement in general.

• Roster billing of inoculations covered by Medicare, except for those companies that agreed to submit these claims electronically as a condition for submission of flu shots administered in multiple states to a single carrier;

• Claims for payment under a Medicare demonstration project that specifies claims be submitted on paper;

• Medicare Secondary Payer 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" (OTAF) adjustment;

• Claims submitted by Medicare beneficiaries or Medicare Managed Care Plans;

• Dental Claims;

• Claims for services or supplies furnished outside of the U.S. by non-U.S. providers;

• Disruption in electricity or communication connections outside of a provider's control expected to last more than two business days.

• Claims from providers that 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 HIPAA standard.

 

The Administrative Simplification Compliance Act

Administrative Simplification Compliance Act Enforcement Reviews

The Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies that a provider did not bill to Medicare electronically. “Providers” is used in a generic sense here and refers equally to physicians, suppliers, and other health care providers. Providers are required to self-assess to determine whether they meet certain permitted exceptions to this electronic billing requirement.

ASCA self-assessable situations are described in the ASCA self assessment page in this section of the CMS web site. In some cases, providers are required to submit a written request to their Medicare contractor to receive permission to submit some or all of their claims on paper. These cases are described on the ASCA Waiver Application page in this section of the CMS web site.

Medicare contractors are required to contact providers that appear to be submitting high numbers of paper claims to verify that those providers meet one or more of the exception criteria for continued submission of their claims on paper. Providers are not to submit that information unless requested as part of an enforcement review. Providers are selected for review based upon the number of paper claims they filed in the prior quarter.

Providers selected for review that are unable to establish that they meet one or more exception criteria, or that fail to respond to a request for the applicable information will have their claims submitted on paper denied effective with the 91st day after the date of the first letter requesting that documentation. One follow-up notice is issued after 45-days if there is no response to the initial request. Providers that submit information to justify their continued submission of certain types or all of their claims on paper are notified by mail whether the information is acceptable and they have been approved for submission of paper claims. These decisions cannot be appealed.