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 at 42 CFR 424.32.
Self-assess to determine if you meet the ASCA exceptions.
Exceptions include:
Small provider claims: Providers with fewer than 25 full-time employees billing an A/B 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 1 or more of those payers made an Obligated to Accept as Payment in Full (OTAF) adjustment
If your self-assessment shows you meet 1 or more of these exceptions, you can submit a paper CMS-1450 claim for each of these exceptions without a waiver request.
Resources
- Electronic Billing & EDI Transactions webpage
- Medicare Claims Processing Manual, Chapter 24