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  1. DAY HIPAA 2003 ...A Region III Production

  2. Medicare Claims The Electronic Submission of Medicare Claims

  3. Background • The Administrative Simplification Compliance Act (ASCA) of December 27, 2001 is the origin of the Medicare electronic claims submission requirement. • Under ASCA, besides the provisions which provided for covered entities to obtain an extension for becoming HIPAA compliant beyond the October 16, 2002 deadline, was the provision requiring the electronic submission of Medicare claims as of October 16, 2003, except in certain limited situations.

  4. Basic Medicare Facts • Medicare is the largest health insurance program in America, serving nearly 40 million individuals at a cost of just under $300 Billion per year. • Although 86 percent of Medicare claims are submitted electronically, the volume of Medicare claims submitted in paper form remains substantial. • Submitting claims electronically is faster, more efficient, and fiscally wise.

  5. Medicare Claims • Claims submitted by Medicare physicians, practitioners, suppliers and other health care providers on or after October 16, 2003 must be submitted electronically in a standard format as specified by the Health Insurance Portability and Accountability Act (HIPAA). • The Medicare electronic submission requirement applies to those providers, physicians, practitioners, suppliers and other health care professionals who bill Medicare Part A or Part B. • There are, however, certain limited exceptions.

  6. Medicare Claims-Exceptions- • Entities who consider themselves small providers • those defined as a provider of services as defined in section 1861(u) of the Social Security Act, with fewer than 25 full-time equivalent employees, • or a physician, practitioner, facility or supplier (other than a provider of services) with fewer than 10 full-time equivalent employees. • Situations where there is no method available for the submission of an electronic claim. • Medicare beneficiaries • where electronic transactions adopted by the Secretary do not support all the information necessary to pay the claim.

  7. Medicare Claims-Exceptions (Cont’d)- • Situations where there is no method available for the submission of an electronic claim. • where electronic transactions adopted by the Secretary do not support all the information necessary to pay the claim (continued) • Three situations meet this category: • Roster billing of vaccinations covered by Medicare • Claims for payment under Medicare demonstration projects, and • Claims where Medicare is the secondary payer to two or more primary payers. • Medicare will issue additional guidance on the requirement for electronic submission of Medicare claims.

  8. Medicare Claims-Exceptions (Cont’d)- • Unusual Circumstances - The Secretary may waive the Medicare claims submission requirement in certain situations. Three situations meet the definition of “unusual circumstances”: • Submission of dental claims • A service interruption • Upon demonstration to the Secretary of other extraordinary circumstances that precluded submission of Medicare claims electronically.

  9. Medicare Claims-Exceptions (Cont’d)- Except for the “unusual circumstances” provision, covered entities that feel they meet one of the other exceptions to this requirement do not have to take any special action. There are no applications or waivers - simply continue to bill Medicare on paper. Absent an applicable exception, paper claims submitted to Medicare will not be paid.

  10. Medicare Electronic Claims The new interim rule is available on our website at Click here for entire rule!

  11. Moving Toward Compliance Guidance on Compliance with HIPAA Transactions and Code Sets after the October 16, 2003 Implementation Deadline

  12. Background • On July 24, 2003, HHS provided guidance regarding its enforcement approach for compliance • The law is clear: October 16, 2003 is the deadline that Congress has given us • HHS wants to ensure that the health care industry understands its enforcement approach in light of concerns expressed about the low rate of readiness • A significant number of covered entities will not be ready to transmit HIPAA compliant transactions

  13. Medicare & Contingency Planning On September 23, 2003 CMS announced that CMS will implement a contingency plan to accept non-compliant transactions after the October 16, 2003 deadline. This is not an extension, nor will this continue indefinitely. CMS will regularly reassess the readiness of it’s partners to determine how long the contingency plan will remain in effect.

  14. Medicare & Contingency Planning • This contingency plan applies only to transaction under the Medicare program. • The authority to implement a contingency plan was provided by the HHS guidance issued on July 24, 2003. • Medicare contractors will be able to accept compliant, as well as non-compliant claims. • This does not affect the prohibition against the submission of paper Medicare claims as enacted under the ASCA provisions.

  15. The Guidance • Dual Goals: • Move all covered entities toward compliance • Avoid disruption of cash flow • CMS will focus on obtaining voluntary compliance and use a complaint-driven approach

  16. Complaint-driven Approach • If CMS receives a complaint, CMS will evaluate the entity’s good faith efforts to comply and give the opportunity to • Demonstrate compliance • Document its good faith efforts to comply and/or • Submit a Corrective Action Plan • CMS will not impose penalties on covered entities that deploy contingencies to ensure the smooth flow of payments, if the entity has made good faith efforts to become compliant. • This determination will be made on a case-by-case basis

  17. “Good Faith Efforts” • Good faith efforts mean that prior to and after the deadline the covered entity makes sustained and demonstrable progress toward HIPAA compliance • For a health plan, “good faith” would also include efforts to assure that they can exchange transactions successfully with their provider network • Demonstrated outreach activities (letters, conferences, phone calls, mailings, website, etc) • Encouraged providers, or those who submit claims on their behalf, to schedule testing, providing testing schedules and statistics showing testing results

  18. Impact • As long as a health plan can demonstrate its active outreach and testing efforts, it can implement contingencies that would allow uninterrupted payments to providers • Contingency example - accept a non-standard transaction after 10/16/03 to allow more time to “test” • This flexibility will permit health plans to mitigate unintended adverse effects on cash flow, business operations, and availability and quality of patient care

  19. Responsibilities • Health plans have special responsibilities to get processes and systems HIPAA compliant • Work with trading partners and conduct outreach • Ensure adequate testing opportunities • Develop contingencies • All covered entities must be prepared to document their “good faith efforts” to comply with the standards if a complaint is filed against them

  20. CMS’ Role • CMS will work with health plans and their associations between now and October • Meet to get assessments of their operations, their progress, and their contingency plans. • Work with the NCVHS to assess the extent to which we are achieving a smooth transition to HIPAA standards • Continue to provide information to covered entities, via our web site, HIPAA Roundtable calls, CMS HIPAA hotline, and askhipaa email

  21. For moreInformation • Visit the CMS website at • Download the “Guidance Document” from our website • Watch the free HIPAA webcast at • Call CMS toll-free at 866-282-0659 or send an email to

  22. Other Contact Information • Website: • CMS E-mail box: • CMS HIPAA Hotline: 1-866-282-0659 • OCR website: • OCR Hotline: 1-866-627-7748 • NY Regional Office: (212) 264-3657 • NYROE-mail address:

  23. For Privacy Contact info for the Office of Civil Right • • 1-866-627-7748 Other OCR Resources: • • Privacy Final Rule / Privacy Modifications Rule • Model “Business Associate Agreement” • • Guidance Explaining Significant Aspects of the Privacy Rule at • • Frequently Asked Questions •

  24. Questions???? QUESTIONS?