"Can I submit a PAPER CLAIM?"
CMS 1500 FAQs
The short answer is, "it depends."
It’s no surprise that healthcare payers prefer to receive claims electronically. Electronic transmission is more efficient, less prone to error, and much faster than a paper-based process.
While most healthcare claims today are submitted electronically, in several situations it’s simply not feasible. These include certain types of claims as well as certain types of providers. Claims for these exceptions are submitted on the CMS 1500 paper form (previously known as the HCFA 1500). These claims contain the same data fields as electronic claims because the electronic data set is based on the form.
You’ll see in the list below the providers who receive automatic or “self-assessment” waivers. For exceptions that don’t fall into these categories, providers must submit a waiver and await CMS’s decision before being approved to submit paper claims.
There are also waivers based on types of claims (as opposed to types of providers) – but these are not covered in this FAQ.
If you don’t find yourself in the list below, you can view Chapter 24 of the Medicare Claims Processing Manual, sections 90.2 and 90.3 through 90.3.3, to see if you fall into a less-common exception category. More than likely, if you are an allowed exception, you will find yourself here.
PROVIDERS WHO CAN SUBMIT THE CMS 1500 PAPER FORM
- Small providers:
- Facilities (who file Medicare Part A claims) with fewer than 25 FTEs; OR
- Physicians/Practitioners/Facilities (who file Medicare Part B or DME claims) with under 10 FTEs
- Large providers who submit fewer than 10 claims on average to Medicare per month.
- Providers who have experienced disruption in electricity or phone/communication services.
- Non-Medicare Managed Care Organizations that bill Medicare for copayments.
There are other exceptions related to types of claims – including, for example, dental claims. And, of course, CMS and other payers accept paper claims from patients.
For more detail on any of these exceptions – including how to count FTE’s to qualify as a “small” provider – see Chapter 24 of the Medicare Claims Processing Manual, Section 90 (the relevant information starts on page 81).
Happy billing!
