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Administrative Simplification Compliance Act Enforcement Reviews

The Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies that a provider did not bill to Medicare electronically. “Providers” is used in a generic sense here and refers equally to physicians, suppliers, and other health care providers. Providers are required to self-assess to determine whether they meet certain permitted exceptions to this electronic billing requirement.

ASCA self-assessable situations are described in the ASCA self-assessment page in this section of the CMS web site. In some cases, providers are required to submit a written request to their Medicare contractor to receive permission to submit some or all of their claims on paper. These cases are described on the ASCA Waiver Application page in this section of the CMS web site.

Medicare contractors are required to contact providers that appear to be submitting high numbers of paper claims to verify that those providers meet one or more of the exception criteria for continued submission of their claims on paper. Providers are not to submit that information unless requested as part of an enforcement review. Providers are selected for review based upon the number of paper claims they filed in the prior quarter.

Providers selected for review that are unable to establish that they meet one or more exception criteria, or that fail to respond to a request for the applicable information will have their claims submitted on paper denied effective with the 91st day after the date of the first letter requesting that documentation. One follow-up notice is issued after 45-days if there is no response to the initial request. Providers that submit information to justify their continued submission of certain types or all of their claims on paper are notified by mail whether the information is acceptable and they have been approved for submission of paper claims. These decisions cannot be appealed.
See the Medicare Claims Processing Manual, (Pub.100-04), Chapter 24, Section 90 for further information.

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