Waivers & Exceptions
In most circumstances, you must submit Medicare initial claims electronically using the X12 837 format. We'll learn more about electronic claims in Lesson 3.
But in some circumstances, you may qualify for a waiver or exception under the Administrative Simplification Compliance Act (ASCA), also known as Public Law 107-105, codified in 42 CFR 424.32.
Self-assess to determine if you meet the ASCA exceptions.
Exceptions include:
- Small health care professional or supplier claims: Providers with fewer than 10 full-time employees billing an A/B MAC or DME MAC are considered small
- Medicare-covered roster billing of flu, pneumococcal, and COVID shots
- Claims for payment under a Medicare demonstration project that specifies paper submission
- MSP claims when there’s more than 1 primary payer and more than 1 allowed amount
If your self-assessment shows you meet 1 or more of these exceptions, you can submit a paper CMS-1500 claim for each of these exceptions without a waiver request.
Resources
- Electronic Billing & EDI Transactions webpage
- Medicare Claims Processing Manual, Chapter 24