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QUESTION: ASCA: What is considered an “unusual circumstance” as listed in the ASCA exceptions?

Answer

CMS interprets an unusual circumstance to be a temporary or long-term situation outside of a providers control that precludes submission of claims electronically and, therefore, it would be against equity and good conscience for CMS to require claims affected by the circumstance to be submitted electronically. Examples of unusual circumstances include:

  • Limited temporary situations when a Medicare contractors claim system would reject a particular type of electronically submitted claim, pending system modifications
  • Documented disability of each employee of a provider preventing the use of a computer to enable electronic submission of claims.

Entities that can demonstrate that information necessary for adjudication of a Medicare claim, other than a medical record or other claim attachment, cannot be submitted electronically using the claims formats adopted under HIPAA.

Disruption in Electricity or Phone/Communication Services: In the event of a major storm or other disaster outside of a provider's control, a provider could lose the ability to use personal computers, or transmit data electronically. If such a disruption is expected to last more than 2 business days, all of the affected providers are automatically waived from the electronic submission requirement for the duration of the disruption.  If disruption is expected to be two business days or less, providers should simply hold claims for submission when power and/or communication is restored.

Medicare contractors can at their discretion approve a single waiver for up to 90 days after the date of the decision notice for a provider if the contractor considered there to be “good cause” that prevented a provider from submitting claims electronically for a temporary period. "Good cause" applied if a provider made good faith efforts to submit claims electronically, but due to testing difficulties, or a similar short-term problem that the provider made reasonable efforts to rectify, the provider was not initially able to submit all affected claims electronically effective October 16, 2003.

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Reviewed Date: 10/15/19
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