Tuesday, June 22, 2010

What is CMS 1500 AND WHO can submit paper claim to Medicare

What is the Form CMS-1500?

The Form CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors (A/B MACs and DME MACs).

A claim is a request for payment of Medicare benefits for services furnished by a health care professional or supplier. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim. Offenders may be subject to penalty for violations.

Exceptions to Mandatory Electronic Claim Submission
The Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies not submitted to Medicare electronically, with limited exceptions. Medicare will receive and process paper claims from health care professionals and suppliers who meet the exceptions to the requirements set forth in the ASCA.

Some circumstances always meet the exception criteria

Health care professionals and suppliers that experience one of these unusual circumstances are automatically waived from the electronic claim submission requirement for either the indicated claim type or the period when the unusual circumstance exists.

A listing of these definitive exceptions and the latest information on CMS regulations regarding the limited acceptance of paper claims in lieu of electronic billing may be found at
http://www.cms.gov/ElectronicBillingEDITrans/05_ASCASelfAssessment.asp on the CMS website. These circumstances include:

• A physician, practitioner, or supplier that bills a Medicare Carrier, A/B MAC, or DME MAC and has fewer than 10 Full-Time Equivalent (FTE) employees.

• A health care professional or supplier experiencing a disruption in electricity and communication connections that is beyond its control.

Health care professionals and suppliers are to self-assess to determine if they meet one or more of these situations and should not submit a waiver request to their contractor. If one of these circumstances applies, they may submit claims to Medicare on paper or via other non-electronic means.

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