Mandatory Claim Submission - JE Part B
Mandatory Claim Submission
Section 1848(g)(4) of the Social Security Act requires that you submit claims for all your Medicare patients for services rendered. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries.
- Exceptions to Mandatory Filing
- False Claims Act
- Assigned Claims
- Nonassigned Claims
- Methods of Submission
- Mandatory Electronic Filing
- Electronic Data Interchange (EDI)
- Contractor Software
- Additional Benefits of Electronic Claim Submission
- Paper Claims
- Denial Only Letter
Providers may not charge patients for preparing or filing a Medicare claim. The requirement to submit Medicare claims does not mean a provider must accept assignment.
Compliance of the claims mandatory claim filing requirements is monitored by carriers. Violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation and/or Medicare program exclusion.
- SSA 1848(g)(4)(A): 'Physician Submission of Claims'
- Requirement to file claims - CMS Internet Only Manual (IOM), Publication 100-02, Medicare Claims Processing Manual, Chapter 1, Section 70.8.8
Exceptions to Mandatory Filing
Providers are not required to file claims on behalf of Medicare beneficiaries when:
- Claim is for services for which:
- Medicare is secondary payer
- Primary insurer's payment is made directly to beneficiary; and
- Beneficiary has not furnished primary payment information needed to submit Medicare secondary claim
- Claim is for services furnished outside United States (U.S.);
- Claim is for services initially paid by a third-party insurer who then files a Medicare claim to recoup what Medicare pays as primary insurer (for example, indirect payment provisions);
- Claim is for other unusual services, which are evaluated by MACs on a case-by-case basis;
- Claim is for non-covered services, unless beneficiary requests submission of a claim to Medicare (a supplemental insurer who pays for these services may require a Medicare claim denial notice prior to making payment);
- Beneficiary signed a Beneficiary Notice of Noncoverage, indicating that no claim should be filed for a specific item or service;
- Provider opted-out of Medicare Program and entered into a private contract with beneficiary (when providers opt-out of Medicare and privately contract with a beneficiary for purpose of furnishing items or services that would otherwise be covered, they cannot submit a claim for such services); or
- Provider has been excluded or debarred from Medicare Program (when provider is excluded or debarred from Medicare Program, claim for services cannot be submitted).
Note: Providers are not required to file non-covered Medicare services; however, many Medicare supplemental insurance policies pay for services that Medicare does not allow and they may require a Medicare denial notice.
False Claims Act
Prohibits knowingly filing a false or fraudulent claim for payment to the government, knowingly using a false record or statement to obtain payment on a false or fraudulent claim paid by the government, or conspiring to defraud the government by getting a false or fraudulent claim allowed or paid. See 31 U.S.C. 3729(a) of the Act for additional details/exclusions/statutory exceptions.
Assigned claims that are filed with Noridian are reimbursed directly to the provider. Certain services, when rendered, may only be paid on an assigned basis:
- Clinical diagnostic laboratory services
- Physician services to individuals dually entitled to Medicare and Medicaid
- Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists and clinical social workers
- Ambulatory surgical center (ASC) facility charges
- Home dialysis supplies and equipment paid under Method II
- Drugs and biologicals
- Ambulance services
Reimbursement for nonassigned claims that are filed with Noridian is sent directly to the patient/beneficiary.
- If you do not accept assignment on a Medicare claim, the Privacy Act prohibits Noridian from releasing certain claims information to you
- The only information about a claim which may be released is if it has been received, paid or its status in the Medicare processing system
- More specific, information cannot be released unless the patient authorizes the release of such information
See the Assignment and Nonassignment of Benefits webpage under Enrollment for additional details.
Methods of Submission
Claims may be filed to Noridian electronically (this applies to most Medicare providers) or on paper (if certain conditions or exceptions exist).
Mandatory Electronic Filing
- Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L. 107-105, and the implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement under Medicare, except from small providers, be submitted electronically as of October 16, 2003, with limited exceptions. Initial claims are those claims submitted to a Medicare fee-for-service carrier, DME Medicare Administrative Contractor, or FI for the first time, including resubmitted previously rejected claims, claims with paper attachments, demand bills, claims where Medicare is secondary, and non-payment claims. Initial claims do not include adjustments or claim corrections submitted to FIs on previously submitted claims or appeal requests.
- Exceptions to this requirement include:
- Small providers, defined as providers of service that submit claims to Medicare Part B that have fewer than 10 full-time equivalent (FTE) employees
- Providers that submit roster claims (generally immunization providers)
- Claims for payment under a Medicare demonstration project that specifies paper submission
- Obligated to Accept as Payment in Full' (OTAF) Medicare Secondary Payer (MSP) claims when there is more than one primary payer
- MSP claims for which there is more than one primary payer and more than one allowed amount. Note: This exception does not apply to claims for which a single primary payer other than Medicare exists.
- Home oxygen therapy claims (applies to providers that submit claims to a DME Medicare Administrative Contractor)
- Claims submitted by beneficiaries
- Unusual circumstances'
- For complete information regarding the mandatory electronic claim filing requirement and exceptions to the requirement, refer to the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 24, Section 90
Electronic Data Interchange (EDI)
- EDI claims are transmitted electronically via telephone lines, via a modem, to Noridian
- EDI filing gives the provider control over the timeliness and accuracy of the claims entry by eliminating the need for mailroom processing and manual data entry by Noridian
- Payment for 'clean claims' may be released by Noridian as soon as the CMS timeframe requirements for claims payment have been satisfied. The payment floor (minimum amount of time, required by law, for which all Medicare carriers must hold payment) is 14 days for electronic claims, as opposed to 29 days for paper claims.
- Submitting claims electronically will result in an overall cost savings from not purchasing paper claims or paying for postage
- For situations in which Noridian requires additional supporting documentation (e.g., requirements noted in a Local Coverage Determination (LCD) or other publication), you may fax supporting documentation with your electronic claim. Refer to the section titled 'Electronic Claims and FAX Attachments' for more information.
Noridian offers courtesy billing software called PC-ACE Pro32. We provide technical support for this software. If you are interested in obtaining Pro32, contact Noridian EDI Support Services.
Additional Benefits of Electronic Claim Submission
In addition to the day-to-day benefits of electronic claims submission, EDI senders may also take advantage of these other features.
- Electronic Remittance Advice (ERA) - This feature allows you to receive paid and/or denied claims information electronically from the Medicare Part B system. ERA can be utilized to automatically update providers' accounts receivable or patient billing system. ERA is equivalent to the Medicare Standard Provider Remittance (SPR) and can eliminate the need to post payments manually.
- Electronic Funds Transfer (EFT) - Whether you are an electronic or paper sender, EFT provides the capability of electronically sending Medicare Part B payments directly to your financial institution.
- Eligibility Accesses - Participating providers who have their claims filed electronically have access to beneficiary eligibility files, via a vendor access. By giving you access to your patient's Medicare eligibility file, you can determine whether the patient is eligible for Medicare benefits; has met his/her Medicare deductible; is enrolled in a health maintenance organization; or is entitled to Medicare under the Medicare Secondary Payer provision.
Medicare Part B paper claims may be filed using only the red printed CMS-1500 (08/05) claim form. This form is appropriate for filing all types of health insurance claims to private insurers as well as government programs. Detailed instructions on completing the CMS-1500 form are found below under the heading 'CMS-1500 Instructions.' The time frame requirement for payment of paper claims is substantially longer than for electronically submitted claims. "Clean" paper claims (claims that are submitted with all required information and without errors) may be paid as soon as 29 days after the date the claim is received by Noridian, whereas electronic claims may be paid as soon as 13 days after the date the claim is received by Noridian.
The claim forms are available as a single sheet, two-part snap-out, one-part continuous, or two-part continuous form. Noridian does not supply CMS-1500 claim forms; however, you may purchase forms from local printers or one of the following offices:
U.S. Government Printing Office
Superintendent of Documents
Washington, D.C. 20402
American Medical Association (AMA)
P.O. Box 10946
Chicago, IL 60610
The Government Printing Office sells negatives for printing the forms. They may be ordered from:
Assistant Superintendent of Departmental Account Representative Division
U.S. Government Printing Office Room C-830
Washington, D.C. 20401
Denial Only Letter
Providers who are eligible to enroll in Medicare must do so if he/she provides covered services to a Medicare beneficiary. Under the Mandatory Claim Submission rule, it is a requirement that providers and suppliers submit Medicare claims for all covered services on behalf of Medicare beneficiaries.
Medicare does not, however, enroll and provide coverage for services rendered by all practitioners from whom a Medicare beneficiary may receive services. The following practitioner's services are not reimbursed by Medicare (not an all-inclusive list): any type of counselor, acupuncturist, massage therapist, non-ambulance transport service.
For non-eligible providers rendering services to a Medicare beneficiary, where the beneficiary is liable, the beneficiary must complete and submit the below items to Noridian. Be sure it is sent it to the appropriate address. See the Mailing Addresses webpage.
- CMS1490S Form (practitioner may assist)
- Provider's itemized bill (required)
- Provider statement indicating that they are unable to bill Medicare because he/she does not meet provider required credentials
The beneficiary will receive a Noridian Medicare Summary Notice (MSN) identifying the claim denial. For instructions on submitting the claim for payment, the beneficiary must contact his/her secondary insurance. Patients may contact 1-800-MEDICARE with questions related to the status of the claim, as the Noridian Provider Contact Center (PCC) is not able to assist them.
Last Updated Thu, 03 Nov 2022 15:24:47 +0000