Submit Only Electronic Claims to Medicare, Except in These Cases

Since Oct. 16, 2003, Medicare has denied all paper claims except in the situations below. Make sure your staff submits your claims electronically unless you meet one of the exception criteria. If you submit a paper claim under one of the exceptions, be sure to respond to a request for more information that you may receive from TrailBlazer, the Texas Medicare carrier. The exceptions include the following:

  • Your practice has fewer than 10 full-time equivalent employees;
  • You participate in a Medicare demonstration project in which paper claim filing is required because the applicable Health Insurance Portability and Accountability Act (HIPAA) implementation guide does not support data essential for the demonstration;
  • You conduct mass immunizations, such as flu injections, and may be permitted to submit paper roster bills;
  • You submit a claim for which more than one other payer is responsible for payment prior to Medicare payment;
  • You furnish services only outside the United States;
  • You are experiencing a disruption in electricity and communication connections that is beyond your control; and
  • You can establish that an "unusual circumstance" exists that precludes submission of claims electronically.

TrailBlazer analyzes reports showing the number of paper claims that all health care professionals submit each quarter. By the end of the month following the quarter, the carrier will review some of the filers who have submitted the highest numbers of paper claims, asking them to submit information that establishes a legitimate exception.

If you are under review for submitting paper claims and do not respond to an initial "Request for Documentation" letter within 45 days of receipt, TrailBlazer will notify you by mail that Medicare will not pay any paper claims that you submit beginning 90 days after the date of the initial request letter.

If you do  respond to the letter, but your response doesn't establish eligibility to submit paper claims, TrailBlazer will notify you of this by mail. This Medicare decision is not subject to appeal.

If you respond with information that does establish eligibility to submit paper claims, TrailBlazer will notify you of this by mail, and you won't be subject to review again for at least two years.

For more information, read  TrailBlazer's Claims Submission Manual  (PDF).


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