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Medicare Compliance & Reimbursement

ELECTRONIC CLAIMS EXCEPTIONS FEW AND FAR BETWEEN

Published on Fri Aug 29, 2003

Providers should get ready to go electronic with their Medicare claims.

When the Health Insurance Portability and Accountability Act transaction rule deadline hits on Oct. 16, if you don't submit your claims electronically, you won't get paid.

The Centers for Medicare & Medicaid Services made that clear in an Aug. 15 interim final rule. The rule formally requires that Medicare claims be submitted electronically starting Oct. 16, with only a handful of exceptions.

The biggest exception: Small providers and suppliers. CMS defines "small" entities as either a) a provider of services with fewer than 25 full-time equivalent employees, or b) a physician, practitioner, facility or supplier with fewer than 10 FTEs.

The rest of the exceptions, as a rule, are pretty arcane. They include:

  • circumstances in which there is no method available for the submission of an electronic claim - claims submitted directly by beneficiaries, for example, would fall into this category, as would roster billing of vaccinations, claims submitted under Medicare demonstration projects and claims where more than one plan is responsible for payment prior to Medicare;

  • dental claims (rare under Medicare); and

  • claims submitted during a service interruption that's beyond the control of the organization submitting the claim.

    CMS notes that organizations can also appeal for special waivers by applying to their carrier or fiscal intermediary.

    Important Note: CMS points out in the rule that it applies to initial Medicare claims, not changes, adjustments or appeals.

    To see the rule, go to www.access.gpo.gov/su_docs/fedreg/a030815c.html.

    Lesson Learned: Work with your payers and business partners in advance to ensure that your claims submission process goes smoothly come Oct. 16.

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