Tips & Information - 5010 NEWS

 

Alert: Tips implement new electronic claim transactions standards 

 

What is 5010?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the healthcare industry use standard formats for electronic claims and claims-related transactions. Because the current version 4010 format cannot support new developments in health care and the upcoming ICD-10 code set changes, all electronic healthcare transactions must convert to the HIPAA-compliant version 5010 on Jan. 1, 2012.

The Department of Health and Human Services (HHS) issued a final rule in 2009 replacing the current versions of the standards with version 5010. Certain covered entities-including health plans, healthcare clearinghouses, and healthcare providers-must adopt the new required standards for claims, remittance advice, eligibility, and claim status inquiry.

 

What does this mean for your practice?The HIPAA 5010 conversion requires substantial changes to the information that is submitted on claims. If these changes are not made, processing of your claims could be delayed.

 

To prepare for the HIPAA 5010 conversion and avoid delays in reimbursement, the most important thing you can do is to contact your practice management software (PMS) vendor or billing service about the changes needed for your software. They can help you identify needed updates and make a plan for implementing these changes to your system.

For example, to be HIPAA 5010 compliant, electronic claims need to include a physical address location. Make sure your system can meet this requirement. Your PMS vendor may need to help you make this change.

 

To help guide your conversation with your PMS vendor, the Centers for Medicare & Medicaid Services (CMS) has a provider checklist on its 5010 Web site that offers sample questions, such as the following:

  • Can your current system accommodate both the data collection and transactions needed for version 5010?
  • If any upgrades are required, when will they be available?
  • Will there be a charge for any upgrades?

Other helpful tips to consider
The following tips can also help your practice ensure a sustainable cash flow throughout the transition to HIPAA 5010:

  • Submit as many claims as possible before Dec. 31, 2011
    Because all transactions submitted on or after Jan. 1, 2012, must be in version 5010, have claims submissions as up-to-date as possible prior to the transition deadline. This step will reduce the number of outstanding claims and increase the ability to complete payment processing for these services without disruptions.
  • Limit year-end expenditures. Consider increasing cash reserves so you will be prepared to absorb any unexpected delays in reimbursement.
  • Establish a line of credit. Arrange access to additional funds through a financial institution, to maintain cash flow if reimbursement is delayed for any length of time. 
  • Make "urgent" corrections to any system issues now.
     
    Prior to the transition period, establish procedures to handle any urgent corrections needed on practice management and billing systems. If system upgrades are done by internal staff, identify which staff members need to be involved. If vendors are involved, find out what processes they have in place to handle urgent needs.
    To make sure your organization is ready for the HIPAA 5010 transition, contact your PMS vendor or billing service today.

A recent Medical Group Management Association (MGMA) study indicated that medical groups are lagging in completing their HIPAA Version 5010 internal testing of their practice management system software and external testing with their major health plans. If you are affiliated with a medical group - it's time to make this happen. January 1, 2012 is just around the corner.

  1. With the new Version 5010, if you currently report any referring provider as an organization name, you'll need to begin reporting him/her as an individual.
  2. Once Version 5010 begins, codes 270/271 will have new mandatory elements including the use of 45 new service codes; and a payer must notify what information is missing in a denial.
  3. The current structure of ICD-9-CM limits code options. The first digit is numeric. In ICD-9-CM, the first digit can only go from 0-9. ICD-10 provides more options. The first digit can be alpha-numeric or numeric, supporting from A-Z before using numbers.
  4. For Version 5010, code 837 now clarifies NPI reporting and billing and pay-to-provider, and supports ICD-10 and COB changes; it also supports only minutes for anesthesia and present on admit indicator.
  5. Codes 276/277, with Version 5010, provides support for prescription numbers and multiple claim identifier; multiple claim status codes are also allowed.
  6. Codes 270/271, with HIPAA Version 5010, require alternate search options using member identifier and date of birth, or member identifier and name. 

 

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