ALS Member Update: August 15, 2003:

Electronic Medicare Claims

On August 15, 2003, the Centers for Medicare and Medicaid Services (“CMS”) published an interim final rule that will require most physicians to file Medicare claims electronically. It will also bring more physicians under Health Insurance Portability and Accountability Act (“HIPAA”) requirements. The new rule is effective October 16, 2003. CMS implemented this regulation pursuant to the Administrative Simplification Compliance Act (“ASCA”). Generally, any Medicare Part A or Part B claim submitted on or after October 16, 2003 by a physician must be submitted electronically to the Medicare Carrier.

CMS exempts the following situations from the electronic submission requirements:

  • If the physician or physician group has fewer than 10 full-time equivalent employees; or,
  • If there is no method available for the submission of an electronic claim (this exception relates primarily to individual beneficiaries)

CMS also provides exemptions for the following “unusual circumstances”:

  • The submission of dental claims;
  • If there is a service interruption in the mode of submitting the electronic claim (this exemption only for the duration of service interruption); and,
  • Upon the demonstration to CMS of “other” extraordinary circumstances which preclude the submission of electronic claims

This new regulation is important for two reasons. First, HIPAA applies to any health care provider who engages in certain electronic transactions, including health care claims submission. A physician now required to submit electronic claims to Medicare will become a covered entity under HIPAA upon the electronic filing of Medicare claims. Once a physician becomes a covered entity (by virtue of filing the electronic claim to Medicare), the physician must comply with the HIPAA Privacy Regulation and the HIPAA Standard Transactions & Code Sets Regulation (and when effective in April of 2005, the HIPAA Security Regulation).

Second, the HIPAA Standard Transactions & Code Sets Regulation also becomes effective on October 16, 2003. Medicare is a covered entity. A covered entity (such as a physician) that conducts an electronic transaction, including health care claims submission, with another covered entity (or the other covered entity’s business associate such as the Medicare Carrier) must conduct the transaction as a “standard transaction.” That means that all electronic claims submitted to Medicare by health care providers on or after October 16, 2003 must be in the standard form required by HIPAA.

Questions also may be directed to the Society's Executive Director, Wesley E. Harrington, CAE, at the ALS Headquarters in Waltham, Massachusetts, at 781-895-9098.

305 Second Avenue, Suite 200
Waltham, Massachusetts 02451
Telephone: 781-895-9098
Fax: 781-895-9088

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American Lithotripsy Society
305 Second Avenue, Suite 200
Waltham, Massachusetts 02451
Telephone: (781) 895-9098
Fax: (781) 895-9088

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