• About Health Care: Submission of Medicare Claims
  • September 30, 2003 | Author: Ellen Steman Fantaci
  • Law Firm: McGlinchey Stafford, PLLC - New Orleans Office
  • Effective October 16, 2003, the Administrative Simplification Compliance Act (ASCA) prohibits the Department of Health and Human Services (HHS) from paying Medicare Part A and B claims submitted on paper. HHS published the rule for Electronic Submission of Medicare on August 15, 2003, and unless certain limited exceptions apply, all Medicare claims for payment must be submitted electronically.

    ASCA operates in the context of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which applies to health plans, health care clearinghouses and certain health care providers, collectively called "covered entities." Medicare, as a covered entity health plan under HIPAA, is therefore required to transmit and receive claims in accordance with HIPAA electronic standards. ASCA takes HIPAA one step further and mandates that physicians, practitioners, suppliers and other health care providers submit claims to Medicare in the HIPAA electronic format, unless one of the specified grounds for waiver applies.

    The general effect of the rule is that some Medicare providers who are not covered entities under HIPAA must conduct a covered transaction with Medicare, in the applicable HIPAA standard. As a result, these providers become covered entities for purposes of HIPAA.

    Exceptions to the requirement to bill Medicare electronically are limited to entities that:

    1. have no method available (beneficiaries and electronic transaction standards that do not support the information necessary to pay the claim);
    2. are considered 'small providers' -- providers of services with fewer than 25 full time equivalent employees (except providers of services such as hospitals, SNFs, HHAs, Hospice, etc.) or physicians or suppliers with fewer than 10 full time equivalent employees; and
    3. qualify as entities with certain unusual circumstances -- dental claims, service interruption, or proof of other extraordinary circumstances that preclude submission of claims electronically to Medicare.