Medicare: Do I Qualify To Send Paper Claims?

The Administrative Simplification Compliance Act (ASCA) monitors and requires that all claims be submitted to Medicare electronically, with few exceptions. There are requirements to submit Medicare paper claims. The exceptions to the electronic claim submission requirements include the following:

• Small provider – a provider billing a Medicare carrier with fewer than 25 FTEs that bills a Medicare carrier;
• Dental claims;
• Demonstration project participant in which paper claim filing is required due to the inability of the Applicable Implementation Guide, adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to report data essential for the demonstration (note: WPS currently does not have any demonstration projects which meet this exception);
• Mass immunizations, such as flu injections, and may be permitted to submit paper roster bills;
• Medicare tertiary claims when more than one other payer is responsible for payment prior to Medicare payment (note: claims in which Medicare is the secondary payer (MSP) are required to be billed electronically unless you meet another circumstance);
• Service furnished outside of the United States;
• Disruption in electricity and communication connections that are beyond its control; and “Unusual circumstance” exists that precludes the submission of claims electronically when expected to last more than 2 business days; and
• Claims from providers that submit fewer than 10 claims per month on average during a calendar year.

Here are the top five most common questions regarding the ASCA.

1.) How do I file for a waiver so I can send paper claims?

You cannot file a waiver to submit paper claims unless you have received an ASCA development letter requesting information from you regarding paper claim submission. Only providers that submit 31 or more paper claims in a quarter or have had a previous two-year waiver receive the ASCA development letters.

2.) I have less than 25 employees. How can I file for a waiver?

If a provider files 31 or more paper claims in a quarter, they will be reviewed by the ASCA Monitoring Department. If you have less than 25 full-time equivalent employees, then you will need to respond to the ASCA department with the correct documentation to receive a waiver which may allow you to continue to submit paper claims. You cannot file a waiver to submit paper claims unless you have received an ASCA development letter requesting information from you regarding paper claim submission.

3.) I am getting my Medicare Secondary Claims (MSP) denied because I am sending them on paper. My software does not allow me to bill MSP claims electronically. How do I get a waiver for my MSP claims?

MSP claims are not an exception to the ASCA requirements. All Medicare claims (see exceptions above) must be billed electronically. You should contact your vendor regarding their software’s ability to send MSP claims electronically. If your vendor software is not capable of filling out MSP claims, you can use another software or our EDI department offers FREE software which is capable of sending MSP claims. Our staff is more than willing to assist you obtaining and supporting this software.

4.) Where do I get a waiver request form to send paper claims?

We do not have a waiver request form. The ASCA monitoring Department will request documentation such as payroll hours for a quarter, a Federal 941 tax form showing the number of employees, a flu roster schedule or a dental license. Documentation is only requested from a provider that submits 31 or more paper claims in a quarter or has had a previous two-year waiver and received the ASCA development letters.

5.) How do I contact the ASCA Monitoring Department?

The ASCA Monitoring Department requests and responses should be done in writing and can be faxed to (618) 998-5230. If you prefer to mail, the mailing addresses are listed below. Please include your contact information on all correspondence.

For IL, and MN:
Medicare Part B
Attn: ASCA Enforcement Review Unit
PO Box 4433
Marion, IL 62959

For MI, and WI:
Medicare Part B
Attn: ASCA Enforcement Review Unit
PO Box 5533
Marion, IL 62959

In addition, please be aware that CMS requires that we review a provider every two years once they have been issued a waiver. If you receive a letter from the ACSA requesting documentation to continue to submit paper claims, you will have 90 days to provide the requested documentation. If you do not qualify or do not respond to the letter within the 90 days, on the 91st day after the letter is sent, your paper claims will be denied.

For information regarding ASCA or paper billing requirements, contact Customer Service at (866) 503-3807.

For questions regarding your electronic claims or getting started filing electronically, contact the appropriate Medicare B EDI Hotline at (877) 567-7261 or visit CMS.