Mandatory Electronic Submission of Medicare Claims

Published 05/01/2023

The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except in limited situations. All initial claims for reimbursement from Medicare must be submitted electronically as of October 16, 2003, with limited exceptions. Initial claims are those claims submitted to Medicare Fee-for-Service contractor, DME Medicare Administrative Contractor, or fiscal intermediary for the first time, including resubmitted previously rejected claims, claims with paper attachments, demand bills, claims where Medicare is secondary and there is only one primary payer, and non-payment claims. This requirement does not apply to those claims submitted by beneficiaries or by providers that only furnish services outside of the United States, to Medicare managed care plans, or to health plans other than Medicare.

All providers are required to submit claims electronically unless they meet one of the following exceptions:

Exceptions

Unusual Circumstances   
  • Claims submitted by a 'small provider' (fewer than 10 full time employees for Part B)
  • Roster billing of vaccinations
  • Claims submitted to Medicare Demonstration Project
  • MSP claims with more than one primary payer
  • Claims submitted by Medicare Beneficiaries
  • Dental claims
  • Services furnished outside the United States
  • Disruption in electricity or phone/communication service for more than two business days
  • Provider submits fewer than 120 claims to Medicare per year*
  • Non-Medicare Managed Care Organization claims billed for copayments
  • Employees have documented disabilities that prevent using computers
  • Other unusual situation documenting that enforcement would be 'against equity and good conscience'

* This includes claims submitted to all Medicare contractors, not only to Railroad Medicare.

Palmetto GBA Railroad Medicare monitors compliance with the requirement to submit electronic claims on a 'post-payment' basis:

  • Palmetto GBA Railroad Medicare will analyze reports displaying the number of paper claims that all providers submitted each quarter 
  • By the end of the month following the quarter, selected providers who have submitted paper claims will be reviewed
  • Palmetto GBA Railroad Medicare will send these providers a 'Review of Paper Claims Submission Practices' letter that explains the ASCA requirements and requests documentation that establishes the provider meets one of the exception criteria listed above
  • Providers who do not respond and/or whose documentation does not support one of the exceptions above will be flagged and paper claims received from those providers will be denied with no appeal rights

Providers who are required to file Part B claims electronically to their local Medicare Administrative Contractor (MAC) are also required to submit claims electronically to Railroad Medicare.

Palmetto GBA Railroad Medicare strongly encourages all providers to submit claims electronically if possible. By law, electronic claims can be paid more quickly than paper claims. Electronic Medicare claims can be paid as soon as 14 days after they are received, while paper claims cannot be paid until at least 29 days after receipt. In addition, processing paper claims has increased administrative, postage and handling costs. See our EDI resources for more information.

Providers who have a signed EDI Enrollment Agreement on file also have the option to submit paperless claims through our eService internet portal. See the eServices User Manual (PDF) for more information. 

If you have received a 'Review of Paper Claims Submission Practices' letter from Railroad Medicare and have questions, please call our  Provider Contact Center at 888-355-9165, Monday through Friday from 8:30 a.m. to 4:30 p.m. for all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m.

Resource:
CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 24, Section 90 - Mandatory Electronic Submission of Medicare Claims.


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