Administrative Simplification Compliance Act Self-Assessment

• The Administrative Simplification Compliance Act (ASCA) prohibits payment of initial health care claims not sent electronically as of October 16, 2003, except in limited situations:
  
  •Small Provider Claims: The word “provider” is being used generically here to refer to physicians, suppliers, and other providers of health care services. Providers that have fewer than 25 full-time equivalent employees (FTEs) that are required to bill a Medicare A/B MAC are considered to be small. Physicians and suppliers with fewer than 10 FTEs and that are required to bill a A/B (MAC) or Durable Medical Equipment (DME) MAC are classified as small. See section 90.1 of Chapter 24 of the Medicare Claims Processing Manual (Pub. 100-04) for more detailed information on calculation of FTE employees and this ASCA requirement in general.
  •Roster billing of inoculations covered by Medicare, except for those companies that agreed to submit these claims electronically as a condition for submission of flu shots administered in multiple states to a single MAC;
  •Claims for payment under a Medicare demonstration project that specifies claims be submitted on paper;
  •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 submitted by Medicare beneficiaries or Medicare Managed Care Plans;
  •Dental Claims;
  •Claims for services or supplies furnished outside of the U.S. by non-U.S. providers;
  •Disruption in electricity or communication connections outside of a provider's control expected to last more than two business days.
  •Claims from providers that submit fewer than 10 claims per month on average during a calendar year.
   
  Providers are to self-assess to determine if they meet one or more of these situations and should not submit a waiver request when they meet one or more of these situations. Please note that some of these situations are temporary or apply only to certain claims, when the temporary situation expires or when billing other types of claims, providers must submit their claims or those other types of claims electronically, and in the HIPAA standard.

See Sections 90 - 90.7 of Chapter 24 of the Medicare Claims Processing Manual (Pub.100-04) for further information on ASCA electronic billing requirements and Enforcement Reviews of providers.