The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.
Providers have a number of options to obtain claim status information from Medicare Administrative Contractors (MACs): • Providers can enter data via the Interactive Voice Response (IVR) telephone systems operated by the MACs.
EDI: Paper to electronic claim crosswalk (5010) The following chart provides a crosswalk for several blocks on the 1450 (UB-04) paper claim form and the equivalent electronic data in the ANSI ASC X12N format, version 5010.
This crosswalk is not intended to be an all inclusive list of every possible electronic media claim (EMC) loop and segment for a particular item on the paper claim form.
Get information on how and when to file a claim for your Medicare bills (sometimes called "Medicare billing"). You should only need to file a claim in very rare cases.
How to Submit Claims: Claims may be electronically submitted to a Medicare Administrative Contractor (MAC) from a provider using a computer with software that meets electronic filing requirements as established by the HIPAA claim standard and by meeting CMS requirements contained in the provider enrollment & certification category area of this web site and the EDI Enrollment page in this section of the web site. Providers that bill institutional claims are also permitted to submit claims electronically via direct data entry (DDE) screens.
For more information please contact your local MAC or refer to the Medicare Claims Processing Manual (IOM Pub.100-04), Chapter 24.
If a response to the letter is not received with acceptable evidence to substantiate eligibility to submit paper claims, all paper claims will begin to reject the 91st day after the date of the letter. This decision cannot be appealed. Responses to this letter can be sent to the following address:
ASCA prohibits payment of initial health care claims not sent electronically as of October 16, 2003, except in limited situations:
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 required to be submitted electronically must comply with the appropriate claim standards adopted for national use under HIPAA or with standards supported under the Medicare HIPAA contingency plan during the period that plan is in effect. The mandatory electronic claim submission requirement does not apply to claims submitted by providers that only furnish services outside of the United States, claims submitted to Medicare managed care plans, or to health plans other than Medicare.
Medicare will not cover claims submitted on paper that do not meet the limited exception criteria. Claims denied for this reason will contain a claim adjustment reason code and remark code indicating that the claim will not be considered unless submitted via an electronic claim.
Medicare contractors are required to monitor and enforce the ASCA regulations. Novitas Solutions will conduct a post-payment based quarterly analysis of paper claim receipts. Following the analysis, a letter will be mailed to the providers who submitted a high volume of paper claims the previous quarter. This letter requests a response explaining which exception is applicable and accompanying documentation to support that exception. If a response to the letter is not received with acceptable evidence to substantiate eligibility to submit paper claims, all paper claims will begin to reject the 91st day after the date of the letter. This decision cannot be appealed.
The Administrative Simplification Compliance Act (ASCA) requires that as of October 16, 2003, all initial Medicare claims be submitted electronically, except in limited situations. Medicare is prohibited from payment of claims submitted on a paper claim form that do not meet the limited exception criteria.
CMS has provided a listing of exceptions to electronic claim submission on its Administrative Simplification Compliance Act Self-Assessment Web page. Some of these include:
The process of billing an insurance company or other third-party payer is difficult to summarize because so much of it depends on variables. These variables include things like the patient’s insurance plan, the payer’s guidelines for claim submission, and the provider’s contract with the payer.
These two forms look and operate similarly, but they are not interchangeable. The UB-04 is based on the CMS-1500, but is actually a variation on it—it’s also known as the CMS-1450 form.
Many plans also have deductibles, which are monetary limits after which the health insurance company assumes the cost of the medical procedure or service.
Likewise, if we’re looking at a patient with coverage under an HMO, but that patient sees a provider out-of-network, we need to know that we can’t send a claim to that HMO, but must instead bill the patient directly. (Recall that HMO subscribers cannot receive insurance coverage if they see providers out of their network).
HIPAA regulations mandate that most claim transmissions be completed electronically. That doesn’t mean that all claims are submitted electronically, though that would probably be ideal.
For one, a practice under 10 employees may use manual claims. Also, a practice that has experienced a power outage may submit claims manually if those claims are time-sensitive.
A relatively recent development in the world of MCOs, CDHPs enable subscribers to receive PPO-like benefits only after they’ve paid a certain deductible. This deductible is usually quite high, but comes with low premiums and a “savings account” that works like a retirement fund.
Claims from providers that only furnish services outside of the United States; Claims from providers experiencing a disruption in their electricity or communication connection that is outside of their control and is expected to last longer than two days.
CMS monitors the suppliers submitting paper claims on a post-payment basis. Each Medicare contractor produces a quarterly report listing every supplier submitting paper claims. Per CMS guidelines, a percentage of the suppliers appearing on that report will be part of the quarterly ASCA Review process. The Medicare contractor sends a letter to the supplier requesting documentation that the supplier meets one or more of the conditions necessary to be excused from submitting claims electronically. The subject line of the letter is "Exhibit C-Request for Documentation From Provider Selected For Review to Establish Entitlement to Submit Claims on Paper."
If so, the supplier is instructed to respond to the Medicare contractor by requesting an ASCA waiver, within 30 days of the Review letter and include documentation to support their response.
The Act was implemented to improve efficiency and reduce the costs associated with processing claims.
If the ASCA waiver is granted, the supplier is notified in writing. If the supporting documents are not sufficient to prove the supplier's position, the supplier is notified in writing and may provide additional documentation.
When a supplier who has not been granted an ASCA waiver submits a paper claim, it will deny with remark codes M117 (Not covered unless submitted via electronic claim) and MA44 (No appeal rights. Adjudicative decision based on law).
If the supplier does not submit a response to the Request for Documentation letter or doesn't include appropriate documentation, an ASCA denial will be assigned to the supplier's file on the 91st day after the date of the initial letter. From that date, all paper claims will be denied unless/until a waiver request and documentation are provided. The Medicare contractor will approve paper claims retroactively if a waiver is granted.
How to Submit Claims: Claims may be electronically submitted to a Medicare Administrative Contractor (MAC) from a provider using a computer with software that meets electronic filing requirements as established by the HIPAA claim standard and by meeting CMS requirements contained in the provider enrollment & certification category area of this web site and the EDI Enrollment page in this section of the web site. Providers that bill institutional claims are also permitted to submit claims electronically via direct data entry (DDE) screens.
For more information please contact your local MAC or refer to the Medicare Claims Processing Manual (IOM Pub.100-04), Chapter 24.